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we move on to the next C clear the big

things about being clear is what is your goal and what is your viewpoint as the author then you should have some logical sequence within your within your poster and it needs to be clear again your poster is something that you want to be

able to catch people it's a one-pager so you can't have too much going on there and then visual clarity is also very important what do I mean by that so your poster should stand alone so you see we have the posters that are right out here

I'm out of this room the poster session was yesterday at 4:00 p.m. the authors are no longer standing by their posters but many of us are still able to walk their reads through and we know what they actually did with their projects so

this is something that's important for you is your poster able to stand on its own whether you're standing with it or not really for you as a presenter you are there to compliment your poster so you're here to highlight things that you

did not necessarily put in your poster or if somebody has further questions to clarify so just remember that your poster should stand on its own so logical sequence so this just a question I'm gonna throw out to

you in the audience how do you usually read posters right how you organize it right so does everybody agree right okay so exactly that's exactly how we read so if you read it that way you want to have that same kind of logical sequence right

top to bottom left to right that's how we usually go and so as you're as you're thinking about what you are writing just you want to be progressive you want to build and you want to try and not be repetitive as you're going through

through your poster so visual clarity so when we're looking at business is more about your pictures your graphs that you use on there make sure they are not blurry so let's look at this look at that picture usually this happens let's

see you take a snapshot of a thumbnail and then you try and zoom it and then it gets all pixelated and then you lose the clarity in your picture or maybe it was just a bad picture like this one where it's just blurry so you want to make

sure you have very clear pictures that you would be able to see pay attention to that when you're working on your poster you're in a PowerPoint that's on a computer screen it's and then it's going to be sized right and you're going

to go and print it out to something bigger so think about what is it going to look like in real life another trick that you can use is as you're working on your PowerPoint when you print it out and you read the paper version the a4

version of your poster if you're able to see everything clearly that you usually should be able to translate into into the bigger poster version your 4 by 8 o or whatever size you decide to go with your poster

all right so sticking with visual clarity color color is is very important and this psychology that actually comes with with color and if you use too many colors within your poster you lose the effectiveness of that poster what is

recommended is two to three complementary colors and you want to consider your color temperatures colors like red yellow tan are your warm colors and usually those are overwhelming to the eye so generally the eye is easy on

your blues and your greens and these are their cooler colors right so they're more inviting and they're easy on the eyes so those are little things that you want to consider as you develop your poster to make sure your colors are not

overwhelming and they would mean people to not want to spend too much time on your poster this test that out okay so here you go this yellow on white what does that look like right you can't really see that so you can't really see

yellow on background so that those are effects of color right on your on your eyes this test is out that's blue over red I've tried I keep looking at this and every time I look at it it's very blurry

there's no trying to focus to look at it it turns out to be blurry even the opposite red over over blue so color psychology is real and and how those colors have an effect on you it's pretty pretty it's pretty consistent so if

you're using these colors and somebody comes and looks at your post or they may not spend too much time because that's just not easy to to look at so if you're going to walk away so these are the things that you're thinking about when

you're looking at clarity

any questions at all so it's very diversified you know most physicians as I stated they don't have a residency I

out you know our fellowship so technologists are in most cases more integrated than cases than you would think here in the US you know a lot of fellowship and residency programs as you know when you have a resident fellow

there their Co scrubbing or they're doing the primary case by themselves whereas they're because you don't have that type of formalized residency structure the interventional technologies is doing all the case

within a physician and that's one of those things that one of the initiatives I'm working on is giving some I are technologists over to help train some of these guys show them how we do it here in the US share and kind of give back

and forth information something that's desperately you need to over in China any other questions thank you guys very much you guys made it through congratulations

so one of the express questions is around staffing and how we're staffing in our departments related to sedation cases versus non sedation cases and also in prepping the patient and recovering

the patient so so basically what our practice has been is that if if it's a non sedation sedation patient we have one nurse on the case if it's a sedation patient then we normally have two nurses on the case in our in our department

that's so that the sedation nurse can focus on monitoring the patient and recording those those vitals and things and then the other nurse can fo can do that given the meds and kind of the you know running running piece of it and

then for pre for for prepping the patient and for recovery we normally just have one nurse that perhaps the patient and one nurse that recovers but if you're in a situation where you say you have very few people you at least

have to have two people present where the patient is being recovered so it depends on your situation and how many beds and whatnot you're working with ours is a little different with the way our setup is we have one nurse in every

lab whether it's sedation or no sedation in our neuro labs we actually have just one nurse in one tack in the body labs and when we're fully staffed we have one nurse in two Tech's we're and I wear a university setting so

our fellows scrubs our techs don't necessarily scrub unless it's a call case or a weekend because we have fellows needs expectation that they learn actively in their process of of growth

in our recovery area our we have a we actually do prep and recovery along with our IR so we're combined so sometimes you're in the IR recovery area and sometimes you're in a lab depends on your assignment that morning in our IR

prep and recovery ideally we have ten days and our goal is to have five nurses so that each nurse has two patients we do prep and recovery in the same area so we kind of you may have a pre patient in a post patient your goal is to not

necessarily have to pre patients but when we cover lunches one nurse goes to lunch and she hands off for two patients to other nurses so during lunch time there are four nurses in that area with the ten patients so it's covered by each

other our charge nurse rotates around do the labs as well in prep room recovery tool and hands whenever there's a need or if there's a patient who's changing our condition that's an issue so we utilize our charge nurse especially in

the labs through our technologists giving a call out if we need help or extra hands and so we're very vocal about utilizing extra help if our condition is changing of our patient and with all my hospitals I have three

really large hospitals two of them or university settings and we run them similar to what you're doing some of the other hospitals I have are a lot smaller so we can't be doing that kind of stuff we don't have as many nurses in those

areas and some of them actually pre and post their patients in their areas so we try to just make sure we have usually have a nurse that's running the nurses and I'm more or less like assigning them and sometimes they'll be assigned the

patient at the beginning follow them through it depends on how the day is going and then or they'll have a you know the nurse in the room if we have a patient that's pretty unstable we try to put two nurses in that room they usually

don't let us have two nurses in imaging with sedation but what we've gotten to do now is the tech scrub so we have usually two texts in the room so at least that frees us up to just manage the patient

and in our university setting we have a lot of fellows which is nice because they do a lot of the scrubbing and I think for us to clarify that the the reason we end up having the two nurses in the room is because it may be but

it's based on hospital policy really what it is so our policy is and it's not just applicable to IR it's any ointment whether to sedation is that the person doing sedation can only be doing

situation and so that's that's where all that stems from we cannot have our person could do in sedation doing other tasks right yeah go with your state you know your your State Board of Nursing what they're they're telling you and

according to your facility to will also recognize though that we do do call cases and when you do call cases in inequality majority of the time you're going to have a tech a nurse and a doctor so in that said not setting what

you definitely do and what you you know in any setting you utilize your nurse from the ICU because in call cases you're usually dealing with an ICU on occasion it may be a needy patient but utilize your nurse down there get a

phone number so that if you do run into trouble it's just the three of you in the lab and you need extra hands you can call for help and you have a one-stop call something so that you're not reaching out and being not being able to

be hands-on with the patient in that situation especially like with your comprehensive stroke I'm sure you have those we utilize the neuro nurses whenever we get one down there because it's one nurse like you said one

physician and then one tech and we usually have them come down to help us out and it's good to have a written workflow about what your backup is when you're in on-call and where that person is coming from if you're adjacent to the

PACU or if you're you know if you're or if it's your ICU nurse that is your backup to have a written workflow so that folks know clearly like where do I get my backup from when I'm in here and off hours okay all right so my question

good afternoon my name is Milly Sattler and I am the unit director of interventional radiology at Emory I brought two of my nursing staff members along with me they're going to help present this where it's going to be kind of a panel discussion and a presentation

at the same time so for the end of this presentation you're going to be able to know the following objectives you'll be able to understand a design project for this quality improvement project explain the outcomes measured for this project

identify the evidence-based practice approach for our project and describe the elements of interprofessional collaboration that contributed to this project Emory Healthcare is in Atlanta Georgia and we have nine hospitals the

physicians basically worked at our Hospital at Emory st. joseph´s but however they also went to different different hospitals and so did the fellows so you'll see why this project was kind of unique because we had to

keep on retraining people to make sure that our throughput worked so this is the hospitals I wanted to show you this is just a little bit of Emory Healthcare by the numbers we have we see over 60 000 patients a year we have 6 000

nurses on staff we have 3 magnet designated hospitals Emory is considered the number one Hospital in the state of Georgia and st. Joseph's is a number two Hospital in Georgia for people that don't know where Emory is it's in

Atlanta and we see patients anywhere from medical surgical patients acute care sub specialties critical care emergencies neuroscience on ecology bone marrow transplant we basically do it all so Emory st. Joseph's is a hospital that

where this project was completed it was founded in 1880 but it was a first hospital in Georgia and is 410 beds and it is a leader in the industry in Atlanta so all of the nurses at Emory are required to be on the

clinical ladder and so part of this project I wanted to make sure that I gave accolades to all the nurses that were on our team so we had nine nurses and every single nurse that was on in this project had a part that they had to

do and for the nurses on this list advanced on the clinical ladder due to this project so part of the background and IR is that first case start times are really crucial it's actually if your first case is not done on time the whole

day cascades into a series of events where you could have some patient safety issues the staff morale goes down there's like over time so it was really important for us to get first time starts so because of the physical layout

of our Hospital our interventional radiology department is on one side of the hospital and the pre-op and the post-op was on another end of the hospital so the patients would come in through the pre-op and the post-op and I

mean I'm sorry just a pre-op then they would come over to us into a holding area and then they would go back after their procedure - to the recovery area however because we didn't have this the nurses like right there to say how the

how's the patient doing when the patient got to us the patients were often didn't have a lot of stuff wasn't done so that was one of the areas where the nurses were the dead stop however because of some of these issues which I'm going to

go through in a little bit the leaders in the hospital and just like yourselves if you're a leader you need to go to the staff and say how can we make this work so we went to the literature and find out how could the leader also help this

team improve so the cases that are dying at interventional radiology is that we do eleven hundred and eighty eight inpatient procedures annually 17:08 outpatient procedures annually 695 CT procedures and 1171 ultrasound

procedures annually the role description of the peak of the staff that was in this in this project where we had for attending interventional radiologists we had for a peepees involved in our project 10

radiology fellows and the fellows went from different hospitals as I showed you in the earlier slide there's like nine hospitals because they're going to different hospitals when the fellow would come to us they might be used to

the old hospital so we had to train them just so that this is how we do it over at st. Joe's to make sure it worked we had six radiology residents there were nine registered nurses nine radiology interventional techs one radiology nurse

navigator and a radiology tech assistant who basically was our transporter and so this whole team consisted of 44 people were involved in this project so when you think about it 44 people that's a lot of people that you kind of have to

make sure that we're all on the same page so our problem statement was due to the multiple relationships in interventional radiology there were a number of variables that were affecting the workflow processes often causing

delay in the first start times of each day so because of that we sat down and we had a meeting with the leaders basically to figure out like what were the problems so we divided them up into six categories we had the patient the

clinical staff the provider the measurements environments and resources and documentation and then underneath on this fishbone you will see the different causes so the patient like the pre-op instructions a lot of times we weren't

sure what the patients were given as far as pre-op instructions because we didn't admit the patient there was a lot of unscheduled appointments where the doctors would say go over to aru that's what that's that was the name of our our

holding area and I'm sorry our our pre-op area go over to aru and I'll check your tunneled cath tomorrow and we didn't know about it there was a lot of patient safety issues like if the patients came in from

the floors for example we'd say to the patient when they got to us when was the last time you ate and the patient would say this morning and so he's up stop I can't do your case and then IV didn't work for us

and then the patients would come to us and they had to go to the bathroom so once we get them to us and we're checking them out like you were sitting in in the pre-op area for two hours and now you have to go to the bathroom like

why couldn't they go to the bathroom before so accountability that's where everyone would say well why didn't we know the patient ate well everybody would kind of blame one another so we made it so that that we we took it as we

were accountable for our own actions we can't control them but we can be proactive to find out like make sure that they know what we need our team structure the way the team worked when we had our daily Huddle's in the morning

the the nurses weren't included it was just the IR tech supervisor the doctor the fellow the a PPS and the nurses were like in the background and I thought to myself wow where's the nurse so we had to kind of fix that and identify the

roles and responsibilities of everybody because the nurse was kind of in the background and the IR tech and the doctor were making a lot of the decisions before this project started the communication plan that we didn't

really have a standard communication plan and so no one knew what was going on with the patient's like the doctors and the nurses were talking to each other and they might call over to the IR tech

supervisor but they didn't let the nurse know so the nurse didn't know that the patient needed an antibiotic or the nurse didn't know the patient's case was going to be like later on that day or even canceled so we had to improve our

communication plan the plan of care that basically went to what if somebody was getting dialysis after their case like no one was telling us what was going on with the patient afterwards the designated start times the nurses when

we first started this project the nurses were and even the staff they were coming in like around 7:00 7:05 7:15 there was like no designated start times and it was kind of making disruption like when

they were giving report people were like interrupting medication reviews the patients might be on Eliquis or a blood dinner and no one was telling us this information so we would be getting ready to do time out and we'd say when was the

last time you had Eliquis and the patient would say today and we'd guess what we can't do your case so this is the stuff that they kind of like where they left the nurse out everybody was kind of working in a reactive process

versus proactive we had the they were measuring some sometimes like like the time the patient got to IR the time the patient got to into the suite however it wasn't consistent so we really could never see where what was causing the

problem the patient tracking board we had a patient tracking board and at that time it was manual and because it was manual they put down the time we thought the procedure was the patient's last name that the name of the procedure was

it three things so we had to Inc we change that we put the time the patient came in that the doctor who was doing the case the case who was going to be the nurse assigned to the case the allergies what was going to be the

insertion site well any medications that the patient might need in any extra tools that we might have needed and even some information about the patient's family we also started triage in our patients like who were going to do first

like one two and three according to the patient's acuity add-ons we were always the last to know about add-on so we could the nurses weren't able to prepare for the case the lack of structure that's where when the nurses came in and

they would come at different times the nurses were kind of like cherry-picking their assignments like Who am I going to take care of like I don't really want to do that you fee today and say she might go to the bathroom

one of those deals so we started assigning the nurses to the room and that one our tracking board as well there wasn't a charge nurse and if there was somebody in charge she was doing cases so if

you're doing cases how could you monitor the daily operations of the case the unassigned cases that went back to cherry-picking and then the workflow processes everybody was doing it a little different we had incomplete

information from the sender care coordination back to that's what we went into we used our radiology navigator to let us know what was going went wrong with the patient the consents it was completely we were getting consents

however everybody was doing in a little differently and then our we had workup sheets did the nurses did for patient safety but they were incomplete so if you look at this you say to yourself wow it's a

hot mess so we had to fix it up and we and we did it took us ten months but we did it so the goal of our project at this point was a project purpose was to reduce patient throughput to 15 minutes or less once the patient arrived to

interventional radiology holding area to the arrival and the procedural suite so we went to the literature to figure out how can we do this project so it talked about a healthy work environment and in a healthy work environment there's that

there is the authentic leader where there's true collaboration and there's open communication so when nurses came with ideas or text came with ideas or the doctors came with ideas we welcomed them we wanted to like try different

things out to see what worked and what didn't work we had a checklist we started our daily morning with who's our patients who's on staff who's in charge who's the doctor we had a schedule printed out on a

bulletin board so we knew what our cases were do we have all the equipment that we need we made a checklist for each patient and we followed it and then because of health care reform today all the hospitals are being required to look

at different care delivery models to make sure that everything ran a little bit more efficiently so that's where we started breaking things down like in that fishbone that I told you about how to do that so because this

was the nurses are on the clinical ladder we had to turn it into an evidence-based practice project and so the clinical question that we used was among the interprofessional team in interment in interventional radiology

does role clarity and responsibilities make a difference an increased patient throughput in a 10 month time frame and back to because I was teaching I was teaching the nurses about the Pico question so we went to Pease our

population among the interventional radiology interprofessional team I the intervention does role clarity and responsibility because we wanted to make sure everybody knew what everybody was responsible for make a difference in can

increase patient throughput which is the outcome in a 10 month time frame that was our t4p code so our project design

know I I come into a new job and you

know I'm all psyched and I'm like I'm ready to do it and you know it's a small team you know I can influence and I realize you know looking at you know what's out there that we really had very little safety and quality metrics and we

were not really measuring much so we looked at the four things the sort of pillars of a quality safety program safety process improvement professional outcomes and satisfaction so you know

okay okay I have this question which is from a friend of mine she said my organization recently moved away from Joint Commission and is now utilizing DNV DET norske veritas has anyone

experienced this credentialing group and what experiences have you had with them I have not really experienced this group and I'm not very knowledgeable about this so if anybody has information please come up to the the and I see you

nodding you were nodding so come up to the microphone because I'd love to hear more about it it's something new on the horizon it sounds like and it's very good to share this information well that's that's my question

and so we just went away from Joint Commission for two reasons one because they're punitive and number two they cost a lot of money so dnv is another credentialing organization that's recognized by CMS and they are more

proactive for setting you up for success as my understanding well they just came last week the day before I left to come here and my director wasn't around and I'm the only nurse in the department so I had the opportunity to take this

clinical person around she asked me very little of what I did even though that I created my own job she was more interested in knowing about the badges that we have and how we handle our radiation and what we're

doing in our art IR lab which is on vascular world opening at the cath lab in two months so she didn't have a whole lot she said she was impressed with what I did but she didn't ask you what I do so I was kind of looking for feedback

for anybody else has experienced this organization so I've worked in facilities that use both Joint Commission one facility I worked in and another facility that use DMV so I've seen them both they are very similar in

the ways that they go around and look at certain guidelines and structures I will say though that DMV is not as punitive they are much more hey this is what we expect how can we help you these are guidelines and they will work with you

and it's not as I don't want to say scary but I remember when I used to work in a facility with Joint Commission it was like terrifying when they came by what DMV it was not as bad they were much more friendly much more willing to

work with you so that was kind of more my experience with them they asked similar questions to Joint Commission as Joint Commission yet who do they look at the similar aspects do they look at outcomes data look at you know mistakes

current entities go around our interventional room and say oh you have to take these posters down because they're not laminated they have to be you know 18 inches yeah so they do a lot they do a lot of the same guidelines as

Joint Commission they just are more willing to work with you and if I'm understand this correctly if this also gets you FEMA your your your Medicaid and Medicare population reimbursement so so what's the limitation on this or this

this company versus Joint Commission because I in California I've never heard of it yeah I'm what state what state Arizona Arizona and what state okay so I'm not in management background so I don't know

aspect of it but from a staff nurse in a procedural nurse in the two areas I've worked in they were very similar in that aspect thank you thank you DMV was with honor health thank you from New York so this is our fifth year at

DMV so they're very into document control which I love because many times new you have nurses copying documents that are 10 years old and the standards has changed so that's what I love about them and they're also when they visit

they give you a list of the things that you need to improve and they come back the next year and they look at those and see what you have done and what results okay thank you so be on the lookout for D and V maybe you're

possibly replacing Joint Commission's okay so we have a one minute time line

includes patients with prior t-ae treatment and liver transplant major medical problems such as cardiac pulmonary and renal disease pregnant or lactating women unable to identify the feeding artery at time of procedure

would exclude participants known diagnosis of cancer other than HCC patients are excluded patients with active infectious disease such as HIV or non-healing ulcer ation and poorly controlled HPV infection are

excluded patients on medication for HPV or HCV are allowed in the study that are required to hold medication on day one of procedure patients with congenital QTC syndrome are preferably a social or associated risk of torsades de pointes

and said antiplatelet platelet inhibitors will require washout periods any major GI bleed in the prior two months of enrollment are excluded and lastly patients who have any clinical evidence of hypoxia with o2 saturation

less than 92% on room air and patients with evidence of arterial and sufficiency or micro angio angiography and any organ due to any reason which could lead to distal extremity hypoxia are excluded all right

so take a minute to imagine well as ever you guys do anybody doing clinical trials in your facility one two okay and

Paul so take a minute to imagine how you would feel would you be excited worried where do you start and how do you keep everyone involved informed how do you prepare the department so the key to a smooth transition requires a project

manager to develop a project plan adhering to the protocol and task requires knowledge and accountability smooth communication between all involved increases the sense of unity amongst the staff successful clinical

trials should cover the entire scope of the protocol some things we considered for our project or the length of time the trial would take and the number of patients being enrolled what resources were already available and what did we

need in addition who would be responsible for which task and how it would go from one part of the process to the other communication between tasks and ensuring that the ones prior got done and the ones after would continue

problems who would problem solve so I'm not expecting you to see the details but I wanted to show you the schedule of events which was included in the research protocol it's easy to follow and it helps understand the entire

process providing a quick glance of which days the patients would require an appointment or testing to be done the patient's are screened during clinic visits with the MD a nurse practitioner patients can expect a detailed HMP

medication review CT MRI imaging EKG lab work hearing tests consent for research and anesthesia screening the nurse practitioner has helped with scheduling all the screening exams prior term Worman

the NPS had additional work trying to get these patients scheduled themselves they had to override the facility's scheduling process already in place all the patient appointments had to be on specific days and in addition a

convenient time and trying to keep these patients compliant so I was going to show you a video but I wasn't able to to download it if some are you're familiar familiar with the chicken little scene the sky is falling

he basically creates panic from his own fears so this is an example of what could happen when information is not available and the staff are not prepared panic mode so at the start of the trials there was no department manager our

newly hired supervisor was wearing three hats as a manager supervisor and more importantly she was just learning about ir the department was preparing for construction to begin which entailed moving cases to the o.r suite and having

to convince the hospital that our patients would have to recover and another unit by other staff nurses our supervisor offered education and support to ensure the accepting units had what was needed to succeed and feel competent

in recovering the AI our patients but it wasn't easy we were understaffed working on hiring both nursing technologists and nurse practitioners we were also just converting moving over to epic so we had

problems getting our orders in place our nurse navigators took the initiative keeping the information as organized as possible and dr. B today offered an introduction meeting prior to the enrollment of the first patient but

there were ly details left unaddressed and regardless tpz trials began because there are multiple pharmacies at large facilities such as UC Irvine one of our nurses created a diagram to help better on

the process of getting tpz on procedure day so when there's an issue you have to know where the process begins and ends the ten steps involved the research coordinator child cancer center pharmacy which they're in charge of research and

the inpatient pharmacy which is where IR is used to picking up their medications from you can call either of the three involved and not get what you want unless you know what the process stopped the diagram shows the complete process

going from orders confirmations second verifications preparation initiation release and dispensing tpz having the tpz available on the day of the procedure was its own involve tasks so nursing had a lot to be concerned with

the physical exams like I said we were started off and we were having construction done so the big question was who was going to bring these patients back and where were they going to be these were 15-minute exams but we

really didn't know what to do with them it was something as simple as height and weight but to train all the 15 nurses that we had was a little bit stressful patient lay is on these patients were being scheduled on specific days and

they needed specific phone calls no one was really familiar with the protocol except for the NPS and the nurse so our question the nurses was who's going to take care of their calls and their questions and what about insurance and

authorization we had no idea when things came through and said it wasn't approved or wasn't paid for we didn't know what to do about it the tpz orders the pump the IV pump that we needed we had no training on it we

didn't have special tubing we didn't know if there was any risk involved for the nurses and the techs the nursing again the labs the frequency of the labs where the order is going to be an epic epic were they going to be specific or

were they just the standard orders overnight observations hell these patients would be monitored for and what could we expect anything different from the chemo ambos the radiology techs they were concerned with

the positioning bacome being software the radio translucent leads and again special handling of tpz and then recovery any non-standard orders for tpz compared to chemo Ambo there were a few so we were concerned with that it all

appears to be standard and easy however our circumstances were not optimal at the start after several months the department hired a nursing manager and nurse practitioner ir received support from the non clinical research

coordinator and the learning curve plateaued the department now has a defined point person a defined III IR RN to focus on we've initiated a collaborative working team with IR RN + P and research coordinators while

looping in our investigating md guidelines and protocols have been rebus revisited and redone explicitly per trial study the nursing has created a combined a common binder for all the trial studies which include the

protocols and preference and this is continuously being updated increased colleague interactions and communications between the research coordinator the NPS and the RNs for a better patient experience have decreased

delays and service improved communication with PPC U which is where our long-term recovery patients go are now guided and have assistance from the RNs research coordinator communicate via email and they come to our physical

meetings for updates and changes we now see increased participation in the IR staff and the trial studies and cross-training I would expect any clinical challenge any clinical trial to have its

challenges but the better prepared you are at the start the better experience you will have so this is our pre procedure orders this is what was different from the standard clinical trial patients require blood draws and

EKG monitoring so we had a second IV and a second pulse oximetry because because of the comb being imaging we needed to have full socks on both the upper and the lower extremities antiemetics are not

included in the orders as they would be with chemo ambos and because there are eight plus EKG sets required during the procedure the patients will wear two sets of EKG leads one set for the monitoring and the second set used for

EKG recordings for the research the additional work involved with clinical trials was too demanding on one single RN these procedures are now scheduled with to procedural nurses post procedure orders vary some as well the protocol

requires again lab draws and triplicate EKGs these labs and EKGs are time from the time of T Finzi injection the EKG triplicates are at 1 2 4 6 10 and 24 hours post injection various PK labs measuring the pharmo kinetic levels of

tpz are also required post injection at 1 2 4 6 10 and 24 hours post in addition if these patients become free bile with a temperature of greater than 101.5 protocol requires blood cultures be sent and again you must notify doctor Abhijit

a patient requires anti-nausea medication pain a subjective however the clinical trial patients also have a PCA ordered

so I've been a nurse at UC Irvine in interventional radiology for 12 years I'm a part-time employee which has allowed me to pick up additional shifts doing other roles and one of those other roles is allowed me to go into the clinics as a nurse practitioner before

the position was filled with our doctors seeing the outpatients for procedures today I'll be discussing transforming from clinical IR to clinical trials with syrup as me known as tpz and I have nothing to disclose so this is just a

little bit more about me here's our most a family picture of our most recent trip in Arizona and Antelope Canyon and then Utah yeah this is my husband we've been together 30 years two kids 19 year old son and an 18 year old daughter so I've

included a picture here of our team yeah I've got dr. Nadine abhi today she's our principal investigator on the left upper hand corner technologist on and trained on the lower left-hand corner and then there's a group photo which includes our

four attendings dr. Nadine abhi today dr. Carrie Nelson dr. James cat services and dr. diantha Fernando our nurse practitioners in the center Paul he's in the audience we've got three nurse practitioners two fellows residents

approximately 15 nurses 8 technologists a scheduler nurse navigator RN supervisor and RN manager just to give you an idea of what our sizes we have shared staff from CT MRI and anesthesiology we have 5 procedure rooms

available for body cases and we have one neuro room which is shared by three of our neuro I our attendings UCI has the is a 450 bed capacity hospital and we are the only level one trauma center in Orange

County so in August 2015 dr. Nadine OB today began phase one interventional oncology trials and is currently now in Phase two

we implemented the World Health Organization checklist I'm sure everybody knows about it and hopefully

are using it I believe in safety checklists I believed in that for a really long time again with crew resource when I learned about that in 2000 I really you know felt that that fit kind of my personality because I

like checklist check things off as well as you know that the the information behind the data shows that it's it's improved safety and certainly commute proves communication so I don't know if this is kind of an older book but Atul

Gawande wrote this great book the checklist manifesto it's a real easy read you could read it on the plane on the way home but it really talked about how he was part of a team with the World Health Organization to implement this

checklist and all and develop the checklist it was international and you know they looked at rural hospitals in India and from rural hospitals in India to John Hopkins and you know they looked at all the barriers how they were able

to implement it the sad thing is is that it's not implemented in every hospital and you know I'm currently in another hospital now in Boulder Colorado and I'm an imaging supervisor and they have the

World Health Organization checklist posted I've been there six weeks so you know maybe I'll come back next year but they don't use it you know they I think they use in the Oro our interventional radiology suite and that facility is

embedded in the bar so it's the IR cath labs EP labs they do taverns and all that they have the signage but they don't really know what it is you know so part of the my action plan for the next three months is to educate the staff on

what it is and actually operationalize it for the whole team but this is a great reference and it's a really a fun read but that's the surgical safety checklist I felt that it wasn't really a hundred

percent applicable to our area so we modified it to the North Shore Medical Center briefing timeout debriefing guidelines and you know I that certainly needs to be updated to I think really checklist should be a little bit shorter

you know so um so you can take this back to your facility but I would encourage you to really modify it to meet your your needs of your department maybe some of these things are already done like verification of procedure against MD

order and booking sheet that changed a little bit with epic this is a pre epic document but because we had paper orders coming in so oftentimes what was scheduled wasn't really what was ordered and what was on the booking sheet so it

was important for us to as part of the brief to discuss what the physician ordered what procedure that we booked and then what was really going to be done and it did what were they all congruent right if there was any

mismatch then we brought it up and we know that there's like a bias against like what you think is what's gonna happen and what actually needs to happen so that those three checks helped us decrease the the number of there

interview later bias like I forgot what it's called but anybody know that in here but it's okay so it really helped us you know break down those barriers an airway assessment I mean sometimes it wasn't done and it

wasn't done until after the procedure which obviously it wasn't done so making sure that it was done and holding up the procedure the brief was done before at the time of consent with the team so we implemented this with the brief being

with the team and we did it from small procedures paracentesis to our larger you know tastes and we didn't do one nineties them but they are now and it was a hard sell to our physicians in text to say like really we have to

breathe for a para you know we've done this patient every month we know their labs but I'm like yes because we had an error with the aspiration hip aspiration you know again it was a seroma they really just wanted to aspirate a

superficial seroma and they ended up aspirating the hip joint even though that fluid did communicate it was the wrong procedure so we knew that again like these even these small procedures can have potential for error and and

your colleagues from the Mayo Clinic presented a case for a paracentesis like again it was majorly high-risk patient that had multiple comorbidities for a simple para right so we did it for every procedure and it really helped

standardize the process because we weren't doing one thing for one procedure and another thing we were that was our standard process that we briefed for every case and the debrief we had we had really good results for the brief

and the time out 100% of the time out the brief I think we're I didn't bring the results but like 89 90 percent the debrief was harder because you know there's a lot happening at the end of the case so a lot of times would be like

debrief everything fine yes check the specimen it was labor correctly if there was anything and again we just we said listen it's okay if it's 20 seconds that's fine if it's something

major and you feel like you really need to be brief we're gonna have that debrief after the case after the patience to the next you know department and and that we have time to really talk about what the issues are

I love the afternoon Huddle's for again the Mayo t/o is the Dartmouth team you know the afternoon Huddle's about what the issues were daily and you know how what the action items are to fix those issues because I necessarily wasn't

always in every debrief so I really you know I'll take that back to my next organization and was the audit complete again implement the implementation of the checklist I think I'm short on time and I again no

no brief or debrief is applicable to all scenarios it takes a lot of training and education the the World Health Organization has a nice manual for implementation and you can look at that you really need a champion you know

luckily I had dr. Newman is my champion and certainly we used what the operating room our surgical services was using for their brief and you know we measured the same way they did and again accountability auditing was huge and

then what we did so I'll make this quick because I know I'm short of time we increased communication with the teams to voice their concerns we had patients with airway concerns any patient that the ir team was uncomfortable and

sedating that we increased collaboration communication again using our crew resource kind of you know scenarios to help provide a backbone if you will for a platform for the staff to to be able to voice their concerns we had an

anesthesia summit so we had anesthesia come down and do some education on moderate sedation they also spent two days in the department and realized who these patients are really sick here you know and I think they knew that but you

know again it's in a very disparate location and you know is you know seeing is believing so we did we did some anesthesia black times so we use that block time to put the most high-risk patients into and then we had

again to find roles of one nurse a charge nurse and lead tech sort of running the day we requested to get input from you know clarifying physician epic helped us a lot because our epic system was a patient didn't get on the

schedule until they had a nurse and a physician check to see whether or not the case was appropriate they did a cursory check the Ahrens on the charge nurse and again we're fairly small program doing like you know 12 to 20

cases a day throughout the different modalities so again it's small but our nurse check that the labs the history and physical assess for need for anesthesia or sedation before the case was even booked ok so and then obviously

physician looked at images talked to the referring physician if there are any issues questions again level of monitoring was a joint decision we really looked at prone patients is our high-risk patients to checking labs we

triage the board daily Huddle's we briefed on every case we debriefed we did some mid procedure on long cases Deibert to make sure that everybody was still on board if anybody needed to be relieved and

then we ensured the documentation was complete we did get representation myself in my chair were members of the surgical exec committee so we saw what was going on in surgical services we aligned ourselves pretty closely with

surgical services and we were able to have consistent policies our policy was the same our infection prevention policy was the same so we really looked at aligning with our resources within our organization and then we used a people

link board for transparency so it was kind of people huddle board you know dashboard whatever it was just a weekly check-in of what issues that we were looking at whether or not their specimen labeling issues medication errors any of

the quality improvement efforts you know again our follow-up phone calls any of our lean work that we were doing five essing any new policies and that was a transparent board within the department we had

a lot of joint staff meetings before I came it was like I our text nurses everybody did separate we had group staff meetings we had separate staff meetings we had a weekly notes that I sent out of anything that happened if

somebody presented a safety event then I would feedback with the whole team of what we're doing about it thank you for submitting it this is what we're doing we'll get back to please help us work on it so there's a lot of transparency

we've developed a policy of critical management of critically ill in the imaging suite patients and then these are 2017 results so we went from the lowest quartile and the organization to the highest quartile again you know we

had a small group so a shift of a couple of people made a big difference but you know we're really proud of these results because people felt appreciated they felt that when pressure builds up that somebody was there to help them they

treated people treated with you know you can read that you know people support each other they're given the resources to do the work and you know we still had work to do but certainly the the perception of safety and the standards

were so we really raised the bar and so slow incremental ways to achieve higher satisfaction from the staff staff engagement in patient safety and then these are the different domains you know we had an 18% increase in you know our

expectation of patient safety teamwork so we really sort of increased on every domain the handoffs we we had a solidified but there was still some contention with our departments that we handed off to so we were doing some work

on that after 2017 again to wrap up I'm sorry I'm running late but on that a culture of safety is dependent on teamwork collaboration and communication certainly structure policies procedures standard work quality improvement

transparencies of the keys to success so

so the treatment protocol there are multiple plan phases in this trial phase one is a dose defining study for phase two and phase one the problem primary objective is to define the appropriate dose for the Phase two this space is

completed and it had 23 patients enrolled phase two is trans arterial terrapass amine embolization versus trans arterial chemoembolization so far there are an additional 11 patients enrolled there is a phase 2a

which is trans arterial terrapass mean EMBO with antibody which includes patients receiving anti pd-1 monoclonal antibody immunotherapy at an outside facility prior to their first tpz procedure in iron alright so terrapass

mean is a very I'm gonna read this one off for you as well syrup as mean is a very unique cytotoxic agent that is activated under conditions of hypoxia it is a bio reductive agent that is activated by cellular reductase such as

cytochrome p450 reductase to generate nitrox ID radicals through a one-electron reaction in the absence of oxygen nitrox ID radicals include single and double strand break and DNA to cause

cell death because of this property terrapass mean exhibits 15 to 200 times greater toxicity and hypoxic cells compared with oxygenated cells this agent has been shown to be a radiation sensitizer and synergistic with platinum

compounds so tpz is stored at room temperature and must be protected from light during storage and administration so in phase one tpz was originally given our intravenously I've got a photo there of the med fusion pump that we had to

use as the pediatric in future and then the lapel dal and gel foam so patients received intravenous TPC five minutes prior to the injection of the embolizing agent slip iodine gel foam the IV infusion lasted two to four minutes and

was to be completed the five minutes prior so we are currently in Phase two which again is taste versus tape and the primary endpoint is to compare the efficacy of tape versus taste based on progressive free survival progressive

free survival is a duration from randomization to the date of the first evidence of progression

traveling the dragon these are some things I remember like I said there are more cameras with facial recognition software in China than anywhere else in the world don't embarrass yourself

they'll know you trust me they'll know you at next airport they'll remember you so make sure you don't embarrass yourself I these ideologies and politics divide medicine heals leave your politics at home you're gonna visit

countries that are not necessarily friendly to Western ideology and guess what that's okay I'm not there to talk politics I'm there to talk people and make friends and if you travel abroad you should do that too

it's amazing everybody likes to smile everybody wants their kids to be happy everyone likes a full belly and a roof over their head and to laugh doesn't matter where you are in the world when eating duck tongue watch out for the

bone in the middle of a Christian can tell you about that and yeah I said duck tongue that's right you can eat some strange stuff in China and you're just gonna like it and say thank you and keep on moving listen listen and learn as

much as much as you teach you're gonna learn from these colleagues these international peers are as educated in their own way as you are and you will learn so much from being able to be with them you're not there just to teach

you're there to learn and listen and you'd be wise to take that with you wherever you go and Chinese culture reviewers their elders and place district expectations on the hospitality and etiquette you never leave a table

hungry and sober in most cases and if you don't believe me you can ask Kumar when he gets up here later on about leaving a table over in China it's not gonna happen so

so does anyone have any questions

I have a question about the workup before one of our challenges that we are having in my facility the texts run the we call it run the board and send for the patients so they are doing kind of the workup to see if the patient's ready

an IV and all that stuff one of the issues worth having is with blood thinners we do the time out and we I made it I'm the charge nurse and I had the nurses call out blood thinners as part of the timeout well we're fine

didn't issues with the blood thinners come at the last minute we're about to start and then we find wait they had a blood thinner this morning kind of what you were dealing with so we test the board runner to start you know checking

on blood thinners well they were checking but they're not telling anybody so they're writing we have slips on the board and you know with each patient so they'll write aspirin you know three 18 or whatever so now we're kind of getting

them in the habit of letting the physicians know with your plan how did y'all handle blood thinners like how who was responsible for not only looking up the blood thinners but letting the physician know hey they had Pradaxa this

morning or whatever okay so we started doing our work up sheets the day before so especially for like the if we knew a patient was an inpatient or outpatient like the day before we knew we knew they were on blood thinners we also have a

nurse navigator so the nurse navigator was the one who was kind of giving the pre-op instructions and at that time she would in she'd like go over their medication review with them and say oh I see you're on ella quest or i see you're

on coumadin when was your last dose and then she would tell them and speak with the doctor and say stop taking it on this day so we kind of had that so once they came in to the pre-op area we kind of made note of that and that she would

make note of that in the chart so when they got to the pre-op area that the pre-op nurses were able to see that but they also once again said hey I your medications were reviewed by Erica on this day however has anything changed

in the last 24 hours and we were catching it then the charge nurse would also look up the labs especially like on the inpatients and see and we'd also look at the medication list and see if they're on any blood

thinners also the concentr the people who did the consents where the AP pees in a lot of times the fellows they would also check the chart and see if the patient was on blood thinners now with between the AP PS and the

charge nurses we would try to catch any of those because sometimes it's you know the patient may be on a heparin drip and they end up coming down and we didn't know but with the phone the pre phone call that's made by the charge nurse not

having to be doing doing cases at the time she can concentrate and the AP PS we were able to catch more of these blood thinner issues and notify the physician before we send for the patient thank you one other thing we added that

was helpful is we had a group text so every morning whoever was in charge would start a group text with the physicians that were there that day the fellows the a PPS and the charge nurse so that if there were issues that came

up like if there was an add-on and a patient was on a blood thinner sometimes the doctors don't care they'll say yeah I'm gonna do the case anyway but at least you could send in the group text like this patient took Eliquis at this

time and then they could say let's move forward or no we're gonna need to reschedule this job document in the chart how did you document that you notify the doctor if they were on a blood thinner is that just a note that

y'all do yeah yeah yeah we did we did we did free-standing notes in our documentation yes great job and unfortunately this issue is not isolated to your hospital I I have been traveling around I'm now

at the third hospital but what I have a question for you and some of it you just answered but what is the a PP rule in the in your department I'm sorry what is the advanced practice provider role where do they fit in okay so the a

PPS do a couple things are there any a PPS from Emory here Oh Tracy they do a couple things come on up they're part of our team the both of these both of these Tracy and Erin are two a PPS from Emory and they'll kind of give you the

description there you're part of the 44 I went to a lecture yesterday that told me there was quite a few good afternoon sorry that we came in late but I'm Erin O'Connell this is Tracy Powell we are two of the ATP's that work at Emory

healthcare with our fantastic nursing staff and we couldn't do what we do without them it's as they already mentioned the collaboration between what we know as nurses because we're nurses at heart and what they have been doing

in preparation for the procedure so our primary role is working outpatients is the procedure appropriate for the patient I'm speaking with attending physicians on what would be the plan and then ultimately going to the patient and

describing what was going to happen what are the risks that we've discussed getting the consent you know all that process of getting the consent and then reporting back off any concerns especially in relationship to moderate

sedation a si criteria to our team members who are going to be providing the sedation and many other much more than just sedation and reference to the care of the patient during the procedure so that's sort of kind of the gist of

our role working in collaboration with the physicians and the nursing staff I think if you don't utilize like MPs or pas in your practice I think we do a very good job of sort of bridging that gap

of communication between the procedural team the nurses I mean just to have everyone know what's going on with that patient because in our facility where sometimes the first patient that will lay eyes especially on an inpatient and

to be able to bring those concerns back you know to the team is very very important and we have found that actually going to each patient's room assessing those patients because you really don't know especially about NPO

status we've had so many instances of patients coming and being put on the table ready for a procedure consent hasn't been done they've eaten blood thinners as you just talked about is a big big deal so we sort of bridge that

communication gap by doing that pre procedural in evaluation I hope that was helpful I have a question I also have kind of instituted the workup sheets and getting the nurses involved and getting ahead of the schedule and looking at

who's coming in and add-ons did you guys have any trouble with so the lead tech and the nurse collaborating and I think it's hard sometimes because the techs are so used to looking up the patient's and it was kind of hard for them to give

up that control and I think it was scary for them as well and so I kinda have like this you know so they kind of feel I don't want them to feel like I'm taking things away but they sometimes do feel that way so so yes I had that

problem okay now Eddie didn't Eddie a actually the the tech supervisor because she was so used to running the ship she was so used to making all the decisions so now a nurse is coming in she felt that we were

kind of like taken away part of her job so basically what we did was she gate there was a lot of push there was a lot of pushback to me and a lot of nonverbals and passive-aggressive but we kind of like worked through it a little

bit but here Eddie up with this list and she wrote it out on a piece of paper like this is what the charge nurse is responsible for and this is what you're responsible for and when she was able to see it on paper the

different roles and how she had more time now to go do her inventory to do her billing and and a lot of the pressure was left lifted off of her she actually was okay but it took a little bit of a process but it was because

Eddie was the mediator thank you yes yeah that's a nursing high so my question is that did you only use the lean methodology and data collection and have you employed a three process wherein you don't just look for the

common causes and you ask the all these questions until you get to the bottom or the root cause of a problem okay I'm sorry I don't so the lean methodology would involve who can you speak up in them okay

the lean methodology involves the identification of the problem and then collecting all data you said that you use the lean method and did you have to go to a series of these questions for each program that you encounter and then

you go to the bottom of the the costs not just a common causal but instead you go you ask all the whys and then you go to the root cause of the problem or else you will just have to perpetrate and it's gonna happen and again and again

and again the problem so we went yeah so we went to so when we went to the lean like when you're talking about the fishbone diagram or the or the tie or the measuring because I'm use I'm familiar with the lean methodology

wherein you used you identify the problem with all the background and the data collection and then you look for the root causes right and you do the countermeasures on the right side and implementation and

that will correspond to your PDS a yeah so what we do it was a combination a little bit of everything like the lean thing if we wanted to make it more structured because it wasn't structured so we eliminated all these little extra

pieces that we didn't need as far as some of the causes we identified what the causes were and we thought of ways how can we correct the causes as far as the measurement goes that's where that was we just did some time

measurement it's not necessarily lean but it kind of like fell into that group because we weren't sure where to put it and it was a financial component where we did cut off 10 minutes of each case so it turned out to be like a hundred

and twenty minutes a day which if you took it and we did the math if we were saving like I think it was like four hundred and eighty thousand dollars a month and just in just in just a salaries for employees and and not

including supplies so but we didn't put that in this project we just wanted to just do the basics and when you do the countermeasures did you have to prioritize your problems or you do oh yeah we yeah we we we prioritize for

sure patient safety was first and that's where we have to address that's what we needed to charge nurse in there we needed someone to identify right away and then we figured if we if everybody knew everybody's rules and

responsibilities then even like when the text came by the the nurses responsible responsible for medication review so the text didn't have to worry about that anymore the nurses worried about that abnormal lab results that the nurses own

that the text didn't have to worry about that so once we identified the roles and responsibilities of each of each person on our team then we were able to like move forward okay you're welcome hi my name is Sharon from USC and I first

would like to applaud you for your 15-minute window that was a big endeavor and kudos thank you my question is that how did what mechanisms did you guys go about to alleviate the back of the barriers to your project not just

writing down a list of duties because we have those all the time texts i mean people tend to like cross or go past the limit did you have any real concrete measures that you use to remove the barriers for for your delays

so so as far as our when we removed the barriers that was basically like if if something didn't go as planned we just said okay let's just move forward what did we learn from it and then what like like I didn't want to have this sense of

fear like oh my god we got to get the patient in there where Millie's gonna write us up there was no we didn't do anything punitive it was all like okay we didn't get the patient here on time why well the patient had to go to the

bathroom okay great so now moving forward we start calling a are you saying make sure the patient goes to the bathroom before they come here so we kind of like just kind of Capri and steady reinforcement that the staff knew

they can come to me and they say oh I forgot to check this or oh I forgot to do that I'm like okay well next time try to remember so we had a real positive reinforcement and we celebrated short winds so as we were doing great what I'd

bring doughnuts in or I'd buy lunch or say hey you guys were really doing a great job here so we kind of like did a lot of lunches and like that kind of like rewards thank you is there a way to get a video of this presentation okay

thank you oh yeah there's there's a video and we can send you the PowerPoint if you would like it what can okay okay so when we benched marked we actually one of our physicians was from

University of Maryland so we asked him can you call up there and get their workup sheet well we had some information from Dartmouth what Dartmouth was doing which is a similar organization similar to ours so we find

out what Dartmouth was doing the University of South Carolina one of the nurses knew someone who worked there and she was able to get their work up sheet so we wanted to look at these different workup sheets to see what other places

are doing - cuz they had some good information and we kind of like just a combination of everybody that's when we were working on our workup so that's when we benchmarked people so and then what do you do for emergent cases like

to use tend to get ten or fifteen or twenty emerging cases in a day or you know does that change up your whole schedule you mean is if an emerging Kasich like something's coming it yeah that turns into triage so basically we

would have a huddle in the morning and a huddle at lunchtime or we kind of like regroup with what's going on and in the morning the doctor the doctor triage - he would say I want to do this case first its case second this case third

and he would put a number and then all day long we kept retreating our patients to see how we were going to do them right so then but what do you do if you have like a stroke coming in trauma coming into your other bay and then

they're asking for something else and does that in other words that disrupt your whole day if you get that a lot or just sometimes no well sometime it did but we had we used to run three rooms so we would have a room that we would try

to not keep open but we would do like little cases in them so if something came in we had this room ready to go and we always had a float nurse and the float nurse would be a nurse that would could go in there or a nurse but we did

this one up system as far as our staffing goes we didn't put a nurse we didn't assign a nurse to a room because if our nurse is coming out of a room we had another nurse waiting to go in with the room so we always did this one up so

he kept a day moving all day long yeah that's great like she said rehad Alandra triage with the physician and say look we were getting ready to send for this PICC line do you want us to bump and you want this emergency case on

the table now these are your labs did you see that they're on heparin and you still want to do it so we we immediately and with the AAP peas as well you know we're we're we have that group text going so we can triage those emergencies

and say who do you want to let's bump something so you can get your patient on the table and everybody else kind of has to do a little backlog but yes so so we just triage to with the physician and the a PPS right and it helps that we're

not a trauma center we don't do neural but and you see all the patients and patients that need to get worked up yes or the fellow we have fellows a PP can we hire all of you I just have wait and then do you do trade you have transport

how do you transport the patients because we run into 35 minute delays just in transport alone we we had our tech assistant his name was Rudy we had Rudy do our transporting and then the nurses after the case a lot of the

nurses would take the patients and with with the with the are two nurses would go over and transport the patient if they had to so we used to transport what back and you have a transporter in the department yeah yes but we do a lot of

our transports do the transporter leaves at like 4:30 we the staff end up having to do transports and then you start early last question sorry though you start early everybody do you stay late a lot we work till 8 o'clock Mean Time and

were there till 10 or 12 at night so what we did was we had a couple one nurse came in at 6:30 and she'd get to get today going and then two nurses came in at 7:00 those are our first three cases and then we would have more nurses

coming in at 7:30 and then one coming in at 8:00 the nurse who came in at 6:30 she went home at 5:00 and then the nurse who came in later she stayed later and the other thing that we did we have a call system so we had the nurse who was

on call and see to nurse so that the nurse who was on call was the last nurse to leave for the day but the see to nurse hung around to make sure she didn't need anything because if she did she was there to help

her okay thank you very much okay thank you hi I have a very simple question how many rooms do you have how many procedure rooms for and how many staff do you have and we have nine nine nurses

wow that's a lot so I have very similar challenge what do you do with anesthesia patients or anesthesia patients we cut the day before we let anesthesia no or that morning if we knew they were going to have anesthesia and then anesthesia

would go and see them with the APB's would usually be the ones that say I'm gonna call anesthesia and they kind of like took care of that work for us therefore that's why you have the 15-minute mean that's why you're lucky

thank you well thank you and then one last question I work also in st. Joseph's in orange but I feel like you have the same scenario but my question is who's your manager who's above the nurses with you guys in a radiology

department well at the time at the time I was at the time I was a unit director so I was in charge of all the nurses um we didn't really anyone above me was a specialty director who is over the cath lab okay because my our frustration is

where we're under attack that's that's very hard for us but I'm just lucky that you we have the same system so but we don't have you guys so I guess with this seminar I will implement that to my boss okay thank you thank you very much


I think because we started later we probably do have time for a couple questions if people have any and you may not but feel free I I will make my email public again I'm now in

Boulder Colorado so you know in another beautiful place in the world and I look forward to collaborating with you and and thank you for your time [Applause]

I got a question here it's what what advanced providers does your radiology

department employ nurse practitioners pas or Ras and what is the MP role in your radiology department or duties we we have MPs in our department and in our big Hospital where we were a trauma center along with

we have a transplant center and a high risk OB pediatrics and everything else you can think of we have three MPs employed in our department in radiology and that's what they do they cover that

they make rounds they do procedures they do the Paris we also have a paracentesis clinic and they take care of that and they just do all that I'm a CNS when I before I took the education role I was a CNS there and what I did was run their

wine ID and we did you the you Effie's and anything that was difficult like a biopsy that was going to be difficult to do they refer to me and I'd work them up so yeah do we have they have a lot of room for advanced practice and radiology

now it's really up and coming for us what about you we we use pas in our department and the piays can do the h and PS on the patients and they can also write up their discharge instructions for the patients they help with workups

from requests that are coming in for inpatients they help with communicating with the physicians that are the inpatient physicians putting in the orders and and to make sure that the patients are ready to come down when we

get them on the schedule so that's their basic responsibilities to the flow of the day we have NPS as well our NPS are very similar to both of yours with the inpatient setting our NPS don't work in an out in the outpatient arena they just

work in the inpatient setting ultimately our goal would be to have an outpatient NP because you do find a lot of times patients come in with pre-existing issues that they maybe didn't relay to the nurse navigator on the phone call

they need to be addressed pretty quickly we've had patients come in very sick and need to be transferred down to the IDI so it would help to have an inpatient NP but right now we do have the three I'm sorry

outpatient MP we have the three inpatient and peace that work our patients up and prep them and work along with the physicians as well as the the providers on the on the floor and the ICU to make sure the patient's

appropriate candidate to have the procedure done yeah and we're currently using them in our outpatient settings CAC do you use them for procedures themselves and I think that that's what I think would be a great

to see more of and I think our institution would love something like that nursing wise we would be fully supportive of having NPS actually be more involved in the procedural area we

haven't seen it in our area yet but I know that other hospitals are doing that I think that's a great role for NPS in in IR our pas they do some very simple things like vine removals and things like that but we haven't got they

haven't been more involved I think that would be a good future for NPS in the room so just you know I know Beth Hackett is here and she's very involved physically in procedures you know she was our former president of

Aaron so she is the one MP that I know that is very actively involved in IR as an MP and I think that that's a great role model for and peace for IR in the you know in the future to follow on what know you know we had one for a little

bit it was not successful in Maryland they don't have so a lot of it is based on the law of the state I'm sorry she asked if anybody had an RA in our department and we did have an RA for a short while but they're they're limited

to what your state will allow them to do in in Maryland at that time it was extremely limited in to what she was allowed to do so we weren't able to utilize her in her role to the ability the way that she should have been

utilized so she did find in a position elsewhere where she was able to do more of what her role was trained to do Florida's least restrictive you right we had one and yeah the same thing he couldn't do a lot so he left its rusty

yeah an RA is a radiology assistant okay they actually helped the docs we have three full-time radiologists and two part-time radiologists and Ron are really our the my RA was the first one in Pennsylvania we had

to wait six months for the legislation to get passed so that he could practice as an RA he was a former cab lab tech he's invaluable to the radiologists he does all the fluoro I think so the RA is kind of like the

advanced practice license for a tech leaders exact consent and everything like that yeah so similar to an NP and PA the training massive training and radiology they just think they are seizures they don't do biopsies they say

this was interventional stuff like in the frost to me tubes and that type of thing they put the catheters in for the throws and the Parra's unless the doctor we have a pulmonologist sometimes comes down and does his own he's great with

PICC lines they can see them as outpatients as well call right they out pay they can't write orders like a PA does that prescribe medications they do a history sort of like we do a history if they see an inpatient before that

gets added on like after the nurses are all gone because we don't have 24-hour we're Community Hospital but he there is limits that they can't do everything that a PA does there was some tension at first because some of the nurses felt

like that he was going to take over their job no we work together and that took about three days to work out so they are an asset but they are much more of a helper towards the radiologists themselves they read bone work and then

the one of the radiologist reads over it and has to sign off on it just a lot of it they don't do they don't bring cat scans or MRIs or and he doesn't do mammograms I think that that's another more advanced training

but yeah that's pretty much what an RA does there is programs out there for them he came to Texas in fact to be trained and he went to have clinical in different spots I don't remember exactly where

they were there were at least three before he came back to our department and worked with our Doc's they have a testing center and run because he was one of the first ones that and was there on the front lines of getting the

legislation passed in in Pennsylvania he got loaned out all over the place to get programs started after he became active in in Pennsylvania he recruited one of our Tech's who was interested in some sort of advanced practice now she's in

training for that whether or not she comes back to our hospital though she doesn't she's not tied down with family and husband yet so you know she could end up anywhere but he was very helpful to her because she liked what he was

doing and wanted to get into that so he's been very encouraging for her too so it is a most mostly attacker who picks up it goes on into advanced practice so so the group so the degree is typically a master's degree I don't

know that I don't know a hundred percent that there's not programs out there where it's a certification after bachelors yeah they're registered he's a registered radiologist assistant yes so there could be some programs that have a

third of the certification after a bachelor's degree but what I've seen is a master's degree and they put the heart rate program in place and iced over the bathroom they can floral they can do certain

procedures they can meditation Frank Yeah right mm-hmm yeah so what she was saying because she wasn't at the mic was that there's challenges around their scope and what they can do depending on the state they're in and that and that

kind of is what is prohibitive my understanding is that Florida is the least restrictive state for this role it's actually been around for quite some time but the reason it hasn't grown more is due to - there's the the stipulations

on their scope in each state yeah according to this slide - did they place here yes or do reduced assistant educational program it seems that it's round like a rrt okay and it looks like it's an associate degree 18 months

requirement to finish that's basically what they have here I think I think depends on the the institution that's offering it that's why I said I don't know that there's not certificate programs out there as I know someone who

who is an RA and they had a master's degree I really have a confusion and I think I can hear the rumble around the neighbor or dear - yeah and I think that's the reason we were questioning is it's this person who is better than an

RN who have a BSN degree and all of that I just want to be sure that it it's a it's a completely different Raleigh I just want it's more it's more of a in the lab role working alongside the physician and in practice you know

physically managing the patients in the lab doing the procedures and probably best utilized where you don't have residents or fellows may be an excellent resource for the management of the patients in a setting that's in like a

non university setting yes hi sorry I'm from Christchurch New Zealand and I'm just trying to define the roles of Weber so do your nurses scrub for the procedures with the doctors and who puts your central lines

and like your Peck lines and things like that and so so it depends on the organization you work at I think the majority of us the text would be the one to scrub or if you have a fellow are you know then we'll scrub with them and the

nurses would be the ones who are kind of doing the the movement around the patient and not actually scrubbed in there are some institutions that do still have the nurses scrub so I'm not saying a hundred percent no but the

majority of setups are that the nurses not scrub did it's the tech that's scrubbed in it also depends on the size of your institution so in a university setting you have more access to staff because you have fellows and residents

that need to be trained and they need to be in the lab at the bedside working with the patient you know and doing the procedures so in those situations and the nurses focuses on moderate sedation and our commercials do not scrub and

even when we have Paul we have a tech a doc in Anderson a fellow because the fellows are on-call as well because life is about Paul in a large setting so but I know in community settings like hospitals that you cover the nurses can

or have a different role because it's a much smaller setting it's a different environment and it's a different patient population so maybe you can give us your insight on that well when I first started working in radiology we scrubbed

but we also gave the sedation it you just can't do that it's not safe and we kind of started making our own rules like we all got together and and we just we just went and told the doctors more or less we're looking at what the state

board had and this is in the hospitals and this is what we want this is what we need so I did work with this one physician that he really backed us up with it and he said yeah we were right we you know we should be managing the

patient and not you know scrubbing and and we were ending up most of us now have two texts in the room and we have the nurse managing the patient some of our neuro cases though are comprehend of neuro cases we do have nurses that

scrub those because I do have some physicians they want nurses because of the drugs they're giving during the procedure or we have a bat team and I think a lot of hospitals have gone through that certain teams that the

respiratory or I even had one facility I worked at not the system I have now but we trained our IR staff to put in the PICC lines we have nurse driven we have some nurse driven we do have if you know we have a nurse driven pick team that

works in the hospital setting that will do inpatients and outpatients and you know they have a workup there if they have a liaison with one of our our rate that was expressive aphasia with one of our interventional radiology physicians

and he is their their leader they're sure you know who they go to for any questions if they have any trouble or if there's difficulty getting that pick in then the patient will come to the IR lab and have the issue resolved

in the lab so you took another bit size they do them at the bedside yes they do them at the bedside and for the outpatients they do them in our recovery area it's the sterile procedure they you know take a private room that we have

and they use that there and then it's followed up with an x-ray to make sure it's an appropriate polite place and if there's any problems the patient comes back to IR we'll take them back to the lab and adjust it but our nurses are

excellent they're well trained and they have an their have a really strong background and we really really we don't see their patients very often you know thank you are we doing the questions on the corridor from I don't want to hijack

go ahead yeah that's fine so what go ahead give us your question well it's related I've heard the term scrub okay since I got here on Saturday okay and I just started in IR into such an you arey okay and my

background is the LR okay Oh are we scrub there I'm certified surgical technologist thank you great and since I have arrived in IR we wouldn't know sterile if it bit us in the butt yeah

and I've heard several of my colleagues here say similar things and what we gonna do i I work in a large large institution okay and I have to say I haven't seen a case that's been sterile since I got there okay so so I as my

instructor heard me say from my course I took on Saturday I'm not leaving without good answer so thank you I'm actually glad you brought this up because it is sort of a debate right and when you if you bring this up with you know long

time our folks I our physicians and things they will get very agitated if you compare the IR lab to and O our days we are not in OA and we you know so you can get into this big debate then around that piece so it is a sensitive topic

and and I think that what is very difficult to move people away from is this is how we've always done it this is what we've always done and we're just going to do it until we you know and fall in the grave right and we can't

we've really got to move away from that and one of the things that I am trying to really push in conversations is around evidence-based practice and we have to do this and it's hard to get people to to really take that data and

the evidence that's published and use it and apply to our setting because there's not going to be a bunch of evidence out there if we didn't write it on IR right so we have to be able to take evidence that is out there and apply it to our

setting appropriate and use that to guide our practice I'm on the local board of al RM yes which I've heard of many times when I'm a local board and I'm gonna try and bring those standards - Erin - I've joined

this in December as well so on branding number my right and we and we have a we have our own Erin has we have our own journal yes and and it's the perfect place to get these things published and out there to the group because everyone

who's a member is has access to our journal and that's the way we can share these best practices and evidence-based practice thank you so much and correct me if I'm wrong because I could be but I do remember that and I'm old so my

memory goes but I'm pretty sure they start the whole thing with me but I dye my hair so as far as I remember I'm pretty sure that SAR you know public collaborated sorry thank you thank you for the word collaborated with a ORN and

and did publish their recommendations there is a white paper so I it is out there already you don't reinvent the wheel and si are you know so the physician group adapted that they agreed and adapted that so we should be able to

utilize that anymore you should be able to utilize because I know in our institution we practice according to a RN standards but that's because and we were doing it beforehand but it really made a huge benefit when SAR combined

with a AO RN and publish this information because now you have a background to say hey they are your group of physicians is recommending this here's the white paper let's utilize it so thank you just got my money's worth

in the challenges the challenges moving moving your department if they're not doing that is moving them into those best practices because if the paper can be written but if it's collecting dust it's not doing us any good right we have

to use that so one of the things I want to recommend to everybody for any questions you have if there's something that we don't answer today or something you don't think about today or something that you go back to and you bump into

utilize your errand forum we have a great forum utilize the errand forum because you throw your question out there you you know I'm not on there that much but when I get on I'll scroll through and I'll find questions that I

think I might be able to have answers for and I'll shoot my information out there so utilize your forum for any questions and if you are having trouble getting your group to get into the the recommendations throw a question out and

see what other people have done because we've all bumped into these issues before and we all have ideas and sometimes we just need an influx of new ideas or someone else's idea or pathway and we can utilize it as our own

you know performance on that it's on our errant national website yeah you're a new blood you're a new blood there so so shit here's my challenge to you next year what I would really love to hear since you're sterile it's sterile

processing everything is new to you I would love for you to submit a lecture on the process that you're going to be going through this next year so you can share with us your best practice and if you're not comfortable lecturing

everybody comfortable comfortable lecturing give us a poster share your information with us so we can grow okay so I'm gonna challenge you to a lecture I'm looking forward to it next year so

and IR it's not just IR you know we're in diagnostic ultrasound mammography MRI and interventional radiology so the bulk of the this presentation centers around our safety attitudes questionnaire we

know that the safety attitudes questionnaire are valid and effective methods of assessing the culture and the safety culture of your staff and assesses the strengths and weaknesses and it is a snapshot of the culture

again it's a self-reported tool that the staff take a series of questions and then that the questions those answers are aggregated and presented to the to the leadership as well as the staff to work on together again here's the on the

the twelve dimensions of the patient safety culture it that's embedded in those questions um so these are our really bad results okay it's kind of embarrassing standing up here but I and you know this is real and this is

real in all of our organizations that we are we have vulnerabilities and the staff again had an opportunity to share what they felt that their vulnerabilities were and we could focus on those those key points that we felt

that we needed to improve safety so again problems are dealt can personnel problems they're dealt constructively with our senior management thirty-nine percent you know that's pretty bad morale and this

setting is high against that's a negative one so that means that sixty five percent of this earth sixty five percent of the staff fifty-five percent of the staff felt that this the Morrell was poor right the organization does a

good job only 50 percent felt that they did a good job in training again you can read through disagreements or saw resolved appropriately all necessary information for diagnostic and therapeutic decisions are routinely

available to me that was a real vulnerability for us again local management doesn't knowingly compromise the patient safety they mean they felt that was sort of good but they are saying that there's certainly a huge

opportunity for improvement and then the nurses input is well received by the work setting and then is difficult to speak up and when it perceived a problem in the patient care area so that meant that sixty percent felt that it was

problematic but the goodness oh let me see okay so the contributors to risk our multifactorial right so you know there's three buckets system personnel and behavioral and you can read through those but the biggest piece is that you

know in a safety culture that you're dealing with a team you really want to look at the environment the culture and you know the communication skills all the other things you know we did touch on we looked at you know availability of

equipment and where the equipment was stored I could talk a little bit about our lean process and how we how we [Music] reorganize the department to make it safer and that people knew where all the

supplies were and an emergency they could quickly open a drawer that was laid you know again the work distractions fatigue stress the behavioral side choices of the the staff their attitudes

justifiable breaches choices those are really dealt pretty well with you know and within a just culture framework I'm sure many of your hospitals have a just culture framework if not I would you know encourage you to to google it and

look at it it's a great tool to make decisions of whether or not the behavior that the staff or the the error was avoidable and like egregious or that it we you needed to do education so really started with you know is this an

educational piece what are the standards you know what what's the norms and the department and is this just a major outlier so it really helped we talked a lot about with the staff this just culture matrix because it helped them

understand that it wasn't when an accident or an incident happened that we were going to go through a real rigorous framework to determine whether or not it was we didn't go to oh the person made the mistake we really started with a

systematic approach of did they know did they have the education and the tools to do the job did they was the policy and procedure clear did what's the norm of the organization to follow that policy

because you may have a policy in your department that you know the norm isn't really to follow it and so is that something that's a responsibility of the administrative staff to make sure that the policies are aligned with what you

actually do and if the policies aren't either to orient and train the staff or to change the policy right and then you know the last and final is you know was it a reckless behavior so and those behaviors people people do reckless

things but most people don't do reckless things most people have a lack of education lack of clarity around policies and lack of poor implementation of new policies so we really ensured that the staff understood that that when

there was an error that we would follow the systematic matrix and the organization has actually involved to have a high reliability committee so any accidents that are near misses or Sentinel events

in the organization go to this committee and this committee determines whether or not what what arm and this just culture matrix needs to be followed and it's kind of hard to see but I think it's it's a nice depiction so I'm when you're

looking at your safety attitudes in your culture I think it's really important to look at what's really good in your department and you know sometimes when you change things that it you have to be careful that you don't change the really

good things that are happening so some of the good things before I started in the organization were that 95% of the staff felt that they felt like they were working is a large family they were working here as a large family and they

really did um act that way they had a lot of group lunches and they celebrated each other's successes you know um when somebody you know had a baby or you know took a course you know it was all about each other and they were really a great

team they did know the proper channels to direct questions of patient safety which is ironic because they felt that they didn't have the management support behind it so those were a little incongruous but you know we worked

through those and then they felt again that they they understood that they were more likely to make errors in a tense or hostile situation and they recognized that but they really didn't know what to do about it right and it it was somewhat

contentious with the physicians I have to say there wasn't the greatest relationship between our physician partners we have a radiology group that serve this um department and there were seven radiologists that came and it was

sort of any given day you weren't really sure which radiologists and what sort of the the feeling of the day was so they felt they understood that it was hostile and they understood that that that impacted their day-to-day working but

they again they really didn't know what to do about it so some the things that they specific examples that Illustrated the reflected experiences on the team were that you

know it was hard to speak honestly that they felt that the unit was very fast-paced that they had conflicting information prior to the start of the case there was a overall lack of communication the physicians were

getting information from multiple people and it was redundant and conflicting and again you know again same question from multiple people so there was again inherent lack of communication from one provider one nurse one tech to each

other the schedule was always large I mean that's the nature of our business I mean we had you know 40% add on pretty much every day again I think that's pretty common in our practice the workload is

large and you can't you know catch up we're not considered in our you know they felt as though they were asked to be treated patients that couldn't be treated in our but we weren't considered an O R we didn't get the resources at

the o R had you know there was no educator there was very little administrative support from the senior leaders because we had a sort of ambiguous hierarchical structure and the doctors were being scheduled for

meetings during the day which sounds kind of like not that important but you know if you thought that your day was going to start at 8 o'clock but your physician has a meeting till 9:15 it seems disrespectful right

it seemed seem disrespectful for the staff that was here ready to go and there may or may not be cases scheduled and the patient is there and there was a lot of service recovery related to that so those are our problems sound familiar

and I know I'm speaking to an audience that really lives this and understands it so you know it makes it easier to really have a conversation with you guys because you know you do live it again you know we're on

alby's evidence-based and we know that Joint Commission the Sentinel event alert in 2018 of 2008 said safety quality and care is dependent on teamwork communication and a collaborative work environment so

those really are three pieces that we really looked at over a course of four years to change in our area teamwork communication and collaborative work so when I was looking at okay you

are your procedure rooms are they red

line or pink line okay is what you mean because you kind of threw us yeah well we we are a very small Hospital and we're trying to decide where where we fall in procedures so we're trying to figure out are we actually working

behind a red line or to be following your fall under a ORN or are we a pink line how what is the sterile attire and and how you're cleaning the rooms between procedures and that's what you're referring to

yes in in our our sweets we require everyone to have on full protective gear shoe covers head covers all of that to be in the sweet mm-hmm well yeah we're right and once they open that tray people should not be allowed in the room

unless they have all that protective attire no masks yeah once you take that cover off that tray so I guess that would be your red line is that is that what you're looking at yeah so the next

so a couple a couple of ground rules first of all I'm a fish out of water I'm not your stereotypical position and I always say that uh that that's how I ended up in New Orleans because you can get lost in New Orleans if you're crazy and I said I didn't get I didn't go to

that course where they inserted this stick in your rectum in medical school so I am not politically correct okay and I don't know if any of you know the Jimmy Valvano story but um you know he got up there in front of everybody and

said I got a hundred and fifty holes in my bone so I want to see a little red light blinking what are you gonna do to me and well I'm similar to that if I'm not politically correct and you're offended I would please leave now

because there's nothing you can do to me because I'm on my way out anyway so it doesn't matter but and it's really funny that I just walked in when Vicki marks was talking and I think I'm a product of the early days of interventional because

we would do cases for eight hours and get eight hours of flora back to back it was that when we learned in tips when we were learning and after you read oral and we just take our badge and throw it and and I swear that that's the reason

why I ended up with myeloma anyway so some of this stuff I'm going to talk about I always like to insert humor so it does so it's not morbid and there are slides sometimes I'm you know being Italian I'm

kind of a wuss I cry at raindrops and and some sometimes I cannot get through the slide because it brings back kind of kind of crummy memories but anyway so I entitled this from the other side of the glass and I actually Photoshop that's me

looking at me getting treated in CT so I

basically and a lot of projects you'll see like pre and post but here we had a little bit a little bit of a mix of a

lot of different project pieces so we did lean methodology and that's where we had our data collection tool and Eddie's going to go over our sheet about how we measure time and then we wanted to measure the arrival time to the

procedural time that that's the part that we really focused on our focus groups so we had frequent staff meetings so every Wednesday every Wednesday of every month we had something going on so we would either

have a one-to-one like nurse to nurse or tech to nurse or tech to leader or we had the techs all meeting together on one Wednesday I know the nurse is all met on another Wednesday and then on a third Wednesday we everybody met and we

talked about our findings like what what we thought was going to work the the big thing that we accomplished in these staff meetings was roll clear if it we all knew who was responsible for what and then our implementation plan is

that's when we optimized our tracking board because the doctors were the ones that came forward and said hey I want the insertion site on the tracking board and the nurses said I want that I want the name up there so that they know

who's doing the case as far as the medications on the tracking board everybody wanted to know that so we got some input from everyone and allergies was huge - and then we started the charge nurse role where the nurses were

we I had a group of the nurses and said who wants to be a charge nurse because I knew they wanted they were on the clinical ladder and the way our clinical ladder works is that the nurses start at the clinical level then they could

become an advanced nurse clinician then they go to an instance north clinician - and then a nurse scholar and then a chart and then a shift nurse manager so if you're an advanced nurse clinician - or a scholar you can be a charge nurse

so I had quite a few of those so I said who wants to be a charge nurse because they had lots of experience five of them stepped up and said they wanted to be the charge nurse so because I wanted to be able to show the vision to the to the

to our staff we use Carter's change model and in Cotters change model we started to create a sense of urgency and the reason why we use and so I have the Carters on the it's on the it's on the left right-hand side and on the

left-hand side I have the framework so create a sense of urgency that's where we had the unstructured workflow roles and responsibilities confusion and patient safety concerns especially with when the patient would come down about

the Eliquis or did you eat but those are important things that we needed to know and that those are things that kind of like delayed the cases build a guiding coalition number two and that's where the interprofessional team members all

the doctors the APB's and the nurses were involved involved I was the executive sponsor for the project but we also had to address our other stakeholders which were the nurses in dialysis

and the nurses in the ARU because that's where our patients are coming from them and going back to them and some of the nurses on the floors we had to form a shared vision for change and that's where we we had our staff meetings we

have lots of handouts we had some posters if we had a new change model which you'll see what we did have one we posted it on the wall and in the bulletin boards so that the nurses knew this is what we were doing so it was a

constant reminder remove all communicate the vision so that's where we researched the literature and then we shared the findings and so when we were researching the literature we would sit down and we have access to the library at Emory and

we would find articles that would pertain to our project and we went to a ORN they we used a lot of their work because of the Ori and the Perry OP which really gave us a lot of clarification and some safety guidelines

that we liked then then I printed out the articles for the other nurses and they had part of their project was they had to take the article articles home and read them on their spare time and come back and share at the next staff

meeting what they learned and then we designed the role the charge nurse but here it was the nurses that once I was like super busy so I gave him these articles like I want you guys to look these up they looked and printed them

out they came back and said this is what we want our charge nurse to look like and we also improved our communication methods are tracking board our daily Huddle's and we had lots of pictorials to help and then this way our nurses

were completely engaged and so as a staff so when the staff engagement survey came out because we use like these words if you're a leader in the room we'd say you're so engaged and then when they get that questionnaire do you

feel engaged then they're gonna say yes so your staff engagement scores go up so it was kind of a win-win for everybody and then the remove barriers that's where you empower the staff so basically that's where I was this leader where the

staff would say this isn't working and even though like I kind of had an idea it was gonna work they needed to either find out or if they did something and it didn't work as planned I was never punitive I'm like okay so plan a

didn't work let's try Plan B and because I had that that mindset my staff really trusted me another piece that worked for us is that we we did the PDSA model and we would plan it study it do it and act on it and we kept doing that over and

over and over with a lot of the pieces that we changed in our project then we had the create short-term wins so we had a quality and bulletin board and every month on the quality on bulletin board we would have a data for the impatience

the outpatients and the and then total and we measures like how the patients were going on a like a Ana tracking I forgot what I called that anyways it's a it's a time measurement scale and then we had then we said the next one is

sustain never let up so that's where we always had the constant reminders we kind of had nurses starting to champion different roles we had nurses say to one another like hey you aren't doing it right like the and they were like they

respected each other you're like you okay right I'll go back and change it and they didn't like talk about each other or something didn't work right and then anchor the change is that's where we had our frequent staff meetings we

always did an evaluation houses working we kept our workup sheets in a drawer so we can go back and on it if we had to and then we and then everybody met their performance appraisal criteria and like I said earlier for nurses advanced on

the plan so this was one of the this is one of our biggest breakthroughs is when we changed our leadership model care delivery when I first started it was the doctor and the I our radiology tech makin all the decisions like the nurses

was completely out of it so after we did these different things the doctor was in charge of the clinical treatment so anything that had to do with the patient care he he decided what we're gonna do the are in charge she was in charge of

clinical decisions daily operations and throughput so she basically was the air traffic for IR and then the lead tech which was the IR supervisor previously we changed the role to called to lead tech and they

were responsible for the IR sweeps all the supplies inventory and the IR technologist she cheated their schedule and then we changed it to our interprofessional model so where everybody was important and equal and so

some of the things that organizationally

they looked at certainly medication errors patient falls you know specimen labeling errors that some that's an area that we weren't looking at critical test reporting the lab really took over that piece and they they were looking at the

feedback loop of the critical test reporting certainly Universal protocol we certainly were doing it but we weren't doing any measurement of whether or not we were doing it satisfactorily and meeting all the elements of again

everybody pausing and really going through the complete time out and correct imaging labeling we were having some errors with correct imaging labeling you know they the tech the tech sending the image two packs with the

wrong laterality on the imaging so but we weren't doing any measurement on that professional outcomes they actually had a pretty robust peer review program they were looking at outliers they were peer reviewing cases that were had poor

outcomes but there was very there was no involvement from the operation side so as part of my change process I I did was invited and and certainly attended to all the physician not vascular nonvascular QA so

that I could bring back systems issues to the staff and bring back maybe imaging to them as part of a educational program so that was really something that was again it's minor but it was had a major positive impact on the the

information that was a feedback loop and communication to the team I'm radiation doses we were measuring radiation doses certainly for our patients but they weren't measuring any cumulative doses from different

modalities and procedural times and length of procedures we didn't really have a way to look at outliers and our scheduling was a little bit erratic so the satisfaction piece I think we were doing pretty well with our customer

group we had and I'll show you we had a homegrown satisfaction survey that our radiology department was 99.1% that patients would come back to radiology for an imaging procedure interventional radiology was a little

bit less because of the time delays and some expectation of treatment of pain so when you come in for a procedure and you're expecting that pain is going to be completely relieved of course you're disappointed when you still do have pain

I mean the the initial lidocaine injection really sedation doesn't touch that so you know we looked at how can we educate the patient to say we're going to make them less anxious and as comfortable as we can but they're still

going to be a moderate level of pain particularly for the initial you know enesta two-hour lidocaine injection so we know that staff that are engaged have are much happier and more productive employees and that they have fewer sick

days and lower turnaround turnover rates and employees that are not engaged or satisfied so we did know that and we we didn't have a high turnover rate but we knew that people felt that it wasn't safe so there was a

vulnerabilities with losing staff because of the environment that they worked in as far as referring physicians they did a quite extensive again over the course of the four years marketing of focus groups with our referring

physicians again another of vulnerabilities that we know that our physicians they're not the primary surgeon they don't see the patient most of the time prior to some of these small procedures so they really needed to

groom and educate our physicians that referred patients to us as far as what our parameters were for our anticoagulants as well as what we needed as far as histories and physicals as well as the procedures that they do

because obviously um if there's a poor outcome physicians may be less anxious or less apt to it refer patients to us so we saw changes in volume due to poor outcomes or patients complaints about delays pain lack of communication sort

of chaotic environment that they were in so we really did a lot of work with our chief I mean dr. Newman did a lot of work and myself with the referring physician groups and department meetings going to their meetings talking about

what we're doing presenting to the larger Hospital organization about our safety attitudes improvements and what we were doing to impact quality and safety in our department and that did help with volume so here's our little

homegrown database it was sent out every three months to our patients again we didn't have a huge end maybe five seven ten respondents but um it was enough to know where we needed to focus on and communication of pain was a big one and

delays and then we started giving out like little coffee cards you know cafeteria cards when patients were delayed so we had a metric of if the delay was 15 minutes or greater that we would have a conversation with a patient

in the family and offer them some this just a small token a five-dollar coffee card but it did help you know at least they they knew that we cared we understood that their time was in poor and that we valued their their choice of

coming to our facility and most of the time people didn't want it but at least we offered it right parking would have been a good one though so then the how

finally intraoperative considerations positioning for comb bean tpz photo

sensitivity EKG and lab draws and noting the time of tpz injection so i wanted to say a little bit about comb beam all right who has comb beam at their facility just a few less okay comb beam is medical imaging technique consisting

of x-ray computed tomography where the x-rays are divergent forming a cone the scanning software collects the data and reconstructs it producing what is termed a digital volume composed of three dimensional voxels of anatomical data

that can then be manipulated and visualized with specialized software on the left is a standard floral image and on the right is the comb beam so the red shows the vascular angiography the blue is a tumor and the yellow is a feeding

artery to the term or so dr. Abuja lays a B today is heavily involved with research so the procedure room with Combee was exclusively constructed for her so positioning for comb beam I believe

to be the bigger challenge initially comb being requires the patient to have their arms up high and using comb beam technology increases the procedural time it would be difficult for the patients to maintain that position and keep still

without anesthesia we started clinical trials with nurse assisted moderate sedation and soon learned it was very difficult the majority of our HCC embolization --zz are done with with sedation but we're

now using anesthesia for all of it so the lead in this case was Tom the radiology tech which assisted with the placement of the anesthesia equipment and patient positioning our anesthesia personnel are not only out of their

comfort zone in the I are sweet but unfamiliar with tpz trial and how the comb beam equipment rotates completely around the patient the patient is wearing two sets of leads one for anesthesia and the other for research

the leads are radio translucent to reduce artifact and imaging keeping the lid lid lead in the department took some getting used to one set got thrown away one set was found up in the ICU one set was on the

anesthesia equipment it was hard keeping track of our special equipment there so the pulse oximetry and blood pressure are on the lower extremities for cone beam again to avoid artifact and imaging when we first

started using cone beam the nursing staff administering sedation were disconnecting patients from monitoring so there were short interruptions with viewing vital signs it became risky and time-consuming to do

so during the procedure one set of EKGs triplicates are done just prior to tpz injection so the treat the EKG triplicates are basically they're two minutes apart in sets of three and lastly having to keep the tpz in a brown

bag and protected from light during the transfer nurse to position there's the photo on the left upper corner doctor busy day basically draws a tpz through a three-way stopcock under a sterile towel

while the nurse keeps the syringe in the brown bag poking a hole in the bag just to NIF to just enough to expose the tip of the syringe and attach it to the three-way this way the tpz is protected from light these reminder adjustments

however they were difficult from the standard and it took time for all the nurses and techs to adjust all right so this here is just a group photo Tom I've got Tyler on the right Thanh our technologist and ELISA and myself so I

thought this was a good photo to represent radiology many specialties consult two IR but it just isn't quite known yet by the general population and surprisingly by the medical staff as well there is a quote by dr. Rosa be

published quote the reason the public doesn't quite understand is we deal with so many disease entities and so many body parts it's hard to brand us unquote so I don't know if you guys were aware but interventional radiology is now its

own medical specialty so hepatocellular carcinoma is a primary malignancy of the liver and now the third leading cause of cancer deaths worldwide with over

come from a humble Italian family if you guys notice that's the Sopranos in the background most of my family died from acute lead poisoning this is so one day I'm riding around having a good time

it's a beautiful flora today that turned dark real quickly I I was doing a CT procedure and I had had pain for a long time and getting older I thought you know it's just I'm working out it's just this pain and they took a CT scan and

this is what they saw at no c4 vertebrae so everybody runs in the room lay down on the ground ball ball you're gonna piss yourself all this kind of crap and and I turn on my turn white and my wife was actually the nurse and it was pretty

scary there for a while but this is what happens you have to hear this you have cancer I don't know if anybody in the room is has heard this but it's pretty it's a pretty lousy statement to hear and I went from James Caridi now a

medical record what you see their date and an insurance United Healthcare so you go from a human being to basically a number this was me before I'd like to be the prankster in the group and then you know a couple of days after the

diagnosis this is what I look like for a long time and so I call it from the other side of the glass now I'm looking in on people and I'm and I've had a lot of experience being a patient and this is my patient

resume I was supposed to be dead about four years ago and you can see I can I can read off a whole bunch of these but I've had liver failure for two years which is really hell in New Orleans okay when everybody when you go to angio

Clubman is 49 drunks and you and but I but other things you know and I I've had a sub massive PE that I was supposed to die from I've had five episodes of sepsis I was supposed to die from so it goes on and on and on and here's my

non-political joke okay so um so I had five skin cancers because the drugs you're on are actually worse than the disease and sometimes and so of immunosuppressed you get you get you get other cancers so they had to take my

eyelid off and I joke that they they reconstructed it with my foreskin and you you can see that some of these things here are really horrible to have but the worst thing to have is to be a radiologist and be cockeyed you know so

there's some good things about having cancer and it's you know you can get free good parking you park close and then you know everybody feels sorry for you to come up and they visit you and it's really nice to have a couple of

nice-looking women come up and say hey how you feeling oh I'm really sick you know and then but I'll give you my experience okay and this is both for patients and doctors and and and and extenders and

it's really important and something I learned if you're a patient or if you're

like so basically we asked the staff to envision what was an ideal unit what

would an ideal unit look like and that's part of the safety attitudes debriefs that you really meet with your staff and you ask them what they feel they can how they can improve the department so some of the things we weren't doing morning

Huddle's so morning Huddle's again this is 2013-14 planning end of day Huddle's to look at you know the next day's cases there's a lot of the things the standards that a lot of the organizations are doing now that we

weren't doing timing of being able to speak with a physician a smoother Trent transition know the communication chain we we had a a nurse that was in the holding room that was the charge nurse Ally tech that was in like an office

that was kind of like a cafeteria like kitchen which we've changed again which was a vulnerability in our our group dynamics because you know I'm coming in from a surgical environment and you know in the middle of the department between

the two control rooms was an inside office that had a refrigerator a microwave a coffee maker and people went in and out of that all the time there was a back door that went to the outside so you know the first thing I did on the

first day I was like this is horrible I need to change this you know but then I I really you know I talked to my my team and my leaders and you know they're like Colleen just you know we're gonna make it better but just don't you know rome

wasn't built in a day and so we slowly got some funds to renovate that office we made it an outside lounge for them and then we then we strongly strictly enforce the infection control practices so you know we had we put red lines down

we informed all the physician staff the I mean we had environmental services coming in with regular street clothes into our control rooms so we had a huge effort so it wasn't like we took away we took away but we gave them a

really nice office we moved their lounge into another area and we had a huge Hospital wide communication we posted our infection prevent practices in front of the that last double doors in front of our unit

and so that we you know we didn't change we kept the culture of positivity and collaboration and again food and celebration is so important but we gave them a place to do that and then we enforced the infection prevention

practices as well as moving the charge nurse in with the charge tech so that they weren't a disparate group that we're all a team so that really changed I mean that one little thing of changing where the charge nurse at from an

outside from in another office to right next to the charge tech really changed like within a day the culture because they knew that though those two groups that the RN and the tech were working together as a team again they were easy

to communicate back and forth about changes in the schedule they they understood each other's strengths and weaknesses it wasn't like the text did that the nurses do that it was like our team does this it was a huge culture

change again they wanted working equipment in accessible places and they wanted to staff to come to work on time and get breaks and leave on time you know again the getting to work on time was part of my you know job to make sure

that people got there on time and if they needed to have a change in their schedule because they had to drop their kids off to daycare we had that conversation you know we changed some people's hours so that they could meet

their home life as well as our work life because you know we had some people that were chronically late 15 20 minutes but it was really because they they had an inability really to get there so we looked at that we met with individual

staff who were having those problems and really said how can we make this better for and then we made a contract together to say okay we're gonna change your hours but then you know we're gonna measure

that that you come here and you're on time so that they had ownership of their change and had professional responsibilities the processes were follow consistency against standards scheduling of the outpatients and the

text would be more appreciated and more included again we had a lead tech and she was managing the department before I came in so a lot of my work is really learning the techs role again I knew they were nurses role you know again I

learned the nurses role but I didn't really understand the tech role and I had utmost respect for those texts and the the need for collaboration and and collaborative education because I think sometimes that the text knew a lot about

what was going on with the procedure the nurses felt like they were just sedating and they didn't need to know so really we we asked the text to educate the staff on the procedures the the equipment and it again it was a

team-building kind of opportunity um

I think we've talked a lot about this all through the this conference and with

our SAR partners about the vulnerabilities into the procedure areas we have a heightened risk of adverse events in procedures that are happening in nan-oh our areas ironically you know again the patients are twos deemed too

sick to go to the OU are and they come down to a remote area an interventional radiology hence the need for standards and streamlining and communicate and collaboration again we have you know increased acuity of our patient

population again increased volume of low-risk procedures on high-risk patients remote settings within the hospital our interventional radiology suite was buried behind our radiology department behind Diagnostics it was you

know signage wasn't very good and you know it was behind two double doors that needed to have badge access so that was oftentimes you know something it's minor but it was major when there was an emergency there was a lack of

significant team-building training and I can talk we'll talk a little bit about what kind of things you can do in your organization's that are really low cost for team-building training and then the procedure lists we know that they're

experts in their procedures but they're not trained in crisis management so and they you know luckily I have a team and I had a team of physicians that were aware of that and so we worked on methods of changing that supporting them

and supporting our team so again safety

so my name is Paul I'm one of the nurse practitioners from UCI Irvine healthcare and what am i one of our minerals in there is basically working on patients for consultations doing the patient rounds writing notes ordering labs etc we also have several clinics that we run

at UCI Medical Center involving patients needing consultations for Libra direct therapies ablations and so forth and one of the more recent clinic that we started running is basically treating patients with BPH and so what we would

know inspiration is basically treating and regarding their symptoms and the procedures pretty much called a prostate artery embolization so the main purpose of this patient excuse me the main purpose of this

topics is basically to provide the general information of what the procedures are about illustrating indications risk and to hopefully help our nursing staff to better take care of these patients sorry so first and

foremost I just wanted to thank my team UC Irvine for allowing me to take some time off of work and enjoying Austin and its many food and object and and allowing me to speak to you guys a little bit about prostate ammo on our

pitchers basically you can't I don't know laser printer but our physicians dr. Karen Nelson she's one of our chief of IR dr. Dan through Fernando dr. Nadine a bitch day and dr. James Castro thesis

he's got daughter Kat Reese is our main doctor that does most of our process embolization our excellent iron nursing team and of course my fellow nurse practitioners who is holding the fort back home Pamela and Takara and watch

and Lou sorry but so our objectives for discussions basically to illustrate the indications and benefits of prostate artery embolization we're going to go over the side effects and risk complications associated with this

procedure and also recognize the value of nursing care going starting from the workup leading to the proper process in trot process and post procedure care sort of a brief outline of what we're gonna be

talking about we're just gonna go over the basic fundamentals of BPH as well as the treatment for PAE and the second portion of this lecture is going over how we walk patients up in clinic what we tell patients and we're gonna go

through the proper care and drop care ask well ask the post-op care and we're going to go through a couple of cases in there it's just to describe to you guys how we care for these special population

hot topics is always a popular table and we always try to get to as many questions as we possibly can we're trying something new this year the format's a little different we have we asked for questions to be recorded on to the little three by five cards this

morning and dropped into some bowls that we had sitting in the rooms and our panel has had a chance then to go through the questions pick out things that are in their area of expertise and try to give you the best possible answer

if we run out of time before we get all the questions answered the board and the clinic committee is committed to getting you an answer so we will it may take us a few days but we'll get you an answer to your question okay let's see if we

stumped the panel we may ask for a couple of volunteers who may have an answer they feel is worthwhile the generally just coming up to the mic at random we're going to try to stay away from that because we get sidetracked any

networking session so we're going to try to stick to just the questions that we have and if you have other questions that you didn't think of that you wanted an answer to don't forget we also still have the forum on the website and we

were going to try to encourage a little more activity in that area as well please let us know what you think of this format in your evaluation because there always be planning for next year okay

who we have today is Laura cheek I didn't get them in the order hello Laura is our is an ir person Sylvia Miller she's our pediatric person and Paula wentao ski is all-purpose so I'm gonna

turn this over to them I think we'll just start at this in pick a question and work down and then we'll come back and do it all over again okay so we're gonna give you a little bit about our background so you guys kind of know

where we come from so if there's any specific questions towards the end that are geared towards our specific specialties please feel free to once we open the mic you give us those any questions yes so my name is Sylvia

Miller and my background in radiology is in pediatrics and I helped to write the pediatric modules that we had up on our website if any of you had an opportunity to participate and complete those I also spent time as an IR manager as well so

from from the management perspective and from the pediatric perspective is is where I among our contributions to the panel okay my name is Laura cheek I work at a large University setting I've been there for 26 years I'm old but anyway my

specialty is neuro so I've gone through the neuro ICU for years and then neuro IR and there's been a stroke coordinator so anything neuro I do body as well because our nurses cover both areas since we do call we have to be able to

be able to deal with the trauma or a bleed as well as a stroke or an aneurysm so we cover both areas so I do have some background in body but neuro is my specialty in neuro it's my heart so I try to get into that lab or those two

labs as much as I can and I train all our new neuro nurses in neuro IR because neuro IR is awesome and I'm Pauline Landowski I've been in imaging for over 25 years I'm old too and I'm a clinical nurse specialist

currently I work for Banner Health and I am the system medical imaging educator for six states I have 16 hospitals currently that have IR and I have 42 outpatient clinics and I yeah I do just about any little thing

and everything in imaging all right yeah

so thank you for being here and I'm really honored to be presenting our safety engagement improvement efforts at North Shore Medical Center I was formerly the nurse director of interventional radiology and interventional cardiology at North Shore

Medical Center and my partner in crime dr. Newman wasn't able to be here but I will certainly try to represent her efforts as well so I used the five W's and H of journalism to sort of introduce the topic is my objective

so Who I am again you know Colleen and I came into intervention radiology as a novice nurse in that area I had leadership background in perioperative services pre-op and PACU and a large academic center in you know in

Burlington Vermont and they when I interviewed for the position they I think we're very interested in my skills because I was able to sort of look at the interventional radiology suite sort of as a peri op setting and developed

standards and procedures so we could talk about that as we go further um when so on the safety attitudes questionnaire started was done in 2013 and I will show you those results I started the organization December of

2014 so there had been some engagement excuse-me work before I started but you know I sort of started and continued the collaboration with our medical team and obviously all our staff North Shore Medical Center is a partner's affiliated

facility or at Salem Massachusetts were a 350 bed level two trauma center we are sort of the poor cousin of partners they underwrite they underwrote somewhere between twenty and forty million dollars a year because of our loss we serve an

indigent population and Salem and the surrounding areas as well as the sort of premiere boutique services um for the North Shore clientele as well so we had a very mixed population but not a great payer mix and not a lot of

additional support for training and infrastructure for efforts for improvement of safety so we really had to do it soda from the ground up boots on the ground and we can I'll talk a little bit about what we did and the

background so this is dr. Newman my partner in crime again she I'm sorry she's not able to be here but she was very instrumental again I think if you're looking at changing a culture you really have to have a team

and I was lucky to have a team member in dr. Neumann she's a very accomplished physician and you know the smile tells it all she's very engaging she really wants to communicate the importance of safety obviously she has a history we

all have been in events that you know we and know that we could have done better and we talked a lot about some of the events that were happened in the past and our organization liver biopsies that went bad you know CT procedures that

patients Crumpton the in the procedure room as well as you know sort of near misses and you know small wrong site procedures I say small it's still large but the procedures that we tended to have issues worth where the sort of low

risk high volume and on high-risk patients so we we looked at all that together and we realized that we really needed to improve so the vulnerabilities

question that we have in the air is

related to doing sedation outside of the eye our suite for instance MRI patients and the question is being asked when how is the radiologists evaluating the patient if they're doing a chin PS or who's doing

that and I know that this is a common struggle that when you're not NIR the radiologist addressing the sedation piece of it appropriately we use we use in our but in the pediatric hospital we use our n P to write that to write that

HMP for the patient so that that's documented how do you guys well in our MRI area we have a CRNA who directs all the sedation to make sure patients are appropriate we also have a pedes sedation team that has a pedes CRNA so

we have you know in MRI we have now granted that's during the day because the procedures are done during the day at night we don't particularly do procedures in MRI patients do get MRIs we do have a night nurse who's I are

trained because she covers both IR and MRI and CT and her we don't have an L IP so anything that is done for patients that if it's an ICU patient on trips the ICU nurse does stay and monitor set trips in our mi MRI nurse will help set

everything up make sure the lines are long enough make sure the vent and everything is outside the appropriate lines make sure that you know magnet safety is achieved and make sure everybody's safe but she will not really

do sedation procedures at night because we don't have an L IP so what about you we have we have an MP and we have anesthesia and our bigger hospitals walking around our smaller hospitals it's a bit of a challenge and recently

we changed our consent more or less guidelines and policy and what we're doing is the physicians are actually signing the consent because they are attesting to that they have spoken to the patient about the procedure and if

they're getting sedation that they have spoken to the patient about the sedation and everything else that goes with it so it's kind of hard on the guys right now but they're they're doing it in MRI no but they're in the they're there and

they're in the department like they're right there like next door yeah in our case they are because yes it's the CRNA driven department and they're very conscientious and really you know one they really want to have

hands-on involvement in every patient in MRI we have we've about four four or five MRIs so they're they're present in that area they're all together so if they're not necessarily in the one MRI they're right next door and the other

MRI but they won't they do one you know sedation patient at a time so they kind of keep it really controlled and like I said we have a peds service too so you'll have the body and NP with one and the peds NP with the other and the

nurses are there in a supportive role for those cases yeah and we don't do after-hours unless it's emergent and then the ER is going to have to come up and or the ICU nurses with their patients and for us we may not have the

nurse practitioner there in the department but we always have the radiologist there in the department so they would respond anything and our and our nurses our pals are finding well-versed and addressing

in the emergent in our in our nurses and I'm sure a lot of you are you're pretty assertive with your physicians if you see a problem with a patient right yes so someone's coming up to the microphone he was waving waving but this will be

the last question on this because he's got I mean so what I'm hearing you say is that you have a CRNA doing your MRI sedation for those of us that don't have that luxury of having anesthesia services requires a nurse would require

a nurse to do it with the physician being present I think you were talking about yeah you'd run an L IP so that you come in and preferably you want the L IP to be in the MRI area and not necessarily reading you know further

down the hall right idea designated to but if that's so Joint Commission says that and that medication needs to be ordered before giving so are you guys using a protocol using a some sort of sedation scale to meet requirement we

have the people present so you know for MRI because MRI is a very difficult area to safely sedate in because you really can't see that well is so in our setting that's why we've moved to that model where we have someone hands-on there

even if the nurses are doing moderate sedation the you know the LEP or then in the end CRNA is there so that if anything untoward happens the immediate assessment can you know can be addressed the issue can be addressed you guys that

might be a little different because your settings are different yeah our settings remember this model because we have a lot of patients that you see and it seems like patients really need a lot of sedation for some of our MRI procedures

because of just different issues you know being in a tooth and tube and stuff like that there's a reason why they need the sedation well what with Pediatrics that they need anything more than just one dose of

something Nastasia yeah we don't yet like I said for us we just adapted that new you know with our with our consents because we want the physicians to actually assess the patient you know and I mean it's just I mean we

do it ourselves but they have to use utilize the a sa you know all that and having them right there I mean they're not going to be in the room but at least we're getting them to do that and that way we can get a hold of them quicker

would you brought up an excellent point in order to be in compliance with your in Commission right you do need to have someone ordering and the person would have to be available to order what you're doing which you know would

preferably put them in the room with you or even or at least in the control room while they're doing what you're doing so I mean I'm not trying to create a whole huge problem here but if we're meeting Joint Commission criteria then then we

need to have some then it is pertinent that somebody be in the control room or in the lab giving the orders to the person who is doing this adays we all have different things like that's why we went to the model that we're doing

because we have someone right there all the time we don't let them order like give up to five of versed or no they have to give us a specific dose each time so it's a good question it's food for thought if anybody has any other

ideas on that please put it on the forum because this is a very strong issue and it is something that we as nurses want to make sure that we're you know having the safety of our patients foremost and making sure that we're practicing within

the scope but also making sure that where patients are getting their procedures done you know as ordered okay so definitely put that up in the forum I'd be interested to hear what other people do and how they've resolved

dealing with that

interventional perspective I talk to some of my colleagues you look at this handsome devil right here you guys know

dr. Kumar fantastic guy from Rush University with dr. arseling back there you know Kumar when I asked his opinion he was over in Guangzhou with si our initiative as a visiting professor you know one of the things in his main

for us was that you know even though the government limit some of these things that they want for excess it was amazing to him what they do with what they have you talking about very skilled physicians that we're doing intervention

very complex cases with but out the tools they probably need to do them and certainly when we talked about PA D which is very under-diagnosed and undertreated they're given the tools and the abilities they definitely want to do

more PA d work they just don't have exposure to it and then I talked also to David Trost from Cornell who's also a good friend of mine in ecology that's been overseas and you know his perspective is that you know when you

talk to the Chinese physician the majority of them are very aware of the clinical research going on here in the u.s. they're very well plugged into international societies and know what's going on so when you talk about them

they will speak very eloquently on on the current trials and clinical you know things going on that's you know like I said it was very surprising to me you definitely are dealing with colleagues of equal or even more so international

knowledge than you would imagine so

no way around this I'm gonna read to you the inclusion criteria right off the protocol it's kind of long so confirmed diagnosis I wrote some single line there that can help you follow along confirm diagnosis of HCC number two patients

above age 23 patients with single or multiple nodules HCC who are unsuitable or unwilling for surgical resection or RFA the largest tumor nodule should be less than 10 centimeters in the large largest diameter total volume of tumor

cannot exceed 50% of the liver patients are candidates for trans arterial embolisation no tumor invasion to portal vein or thrombosis and main and first branch of the portal vein 5 patients have no lymph node involvement or

distant metastasis 6 ECoG score at 0 to 1 with no known cardiac pulmonary or renal dysfunction 7 child pew score group a and B 7 eight patient should have measurable disease by contrast MRI nine prior local

therapies such as surgical resection radiofrequency ablation and alcohol injection are allowed as long as tumor progresses from the prior treatment and the patients are still candidates for tae 10 patients have normal organ

function based on some labs eleven patients are able to understand and willing to sign the informed consent and twelve men and women of childbearing age need to commit to using two methods of contraception and the exclusion criteria

today's objectives I'll start with reviewing hepatocellular carcinoma HCC

and the current treatment options I'll share the protocol inclusion and exclusion criteria and I will discuss the research treatment protocol briefly and next transitioning to research the preparation taken in the department with

staff members for trial lastly I will talk about what's involved intraoperatively from a nursing standpoint so hepatocellular carcinoma HCC is the most common primary liver manely malignancy and is a leading cause

of cancer-related deaths worldwide cirrhosis is a condition in which there is scarring to the liver causing permanent damage chronic medical conditions such as diabetes mellitus and obesity lead to chronic liver disease

obesity is a risk factor to diabetes and diabetes directly affects the liver because of the essential role the liver plays in glucose metabolism both cirrhosis and chronic liver disease remain the most important risk factor

for the development of HCC a which viral hepatitis and excessive alcohol intake are the leading risk factors of cirrhosis non-alcoholic fatty liver disease and non-alcoholic steatohepatitis which is nash our

conditions in which fat builds up in your liver thus having inflammation and liver cell damage along with fat in your liver these are other risk factors for HCC the incidence of HCC will continue to escalate as hepatitis C and obesity

become more prevalent in the United States so unfortunately the diagnosis of HCC is too often made with advanced liver disease when patients have become symptomatic and have some degree of

liver impairment at this late stage there is virtually no effective treatment that would improve survival in addition the morbidity associated with therapies unacceptably high modalities available for HCC screening include both

radiographic tests and serological markers radiological tests commonly used for surveillance include ultra sonography multi-phase CT and MRI with contrast ultrasound has historically been utilized to identify intrahepatic

lesions since the early 1980s both the photograph above shows a cirrhotic liver versus a normal liver there are visible differences in the portal and hepatic veins between the cirrhotic liver when compared to the non cirrhotic liver so

AFP alpha-fetoprotein has been used as a serum marker for the detection of HCC an AFP level of less than 10 is normal for adults an extremely high level of AFP in your blood greater than 500 could be a sign of liver tumors liver function

tests or lfts look at the part of your liver that is not affected by cancer to see how well your liver is working the lfts will be considered for diagnosis and determining the stage of HCC the tests look for levels of certain

substance in your blood such as bilirubin albumin ALP ast alt and GGT despite advances in prevention techniques screening and new technologies in both diagnosis and treatment incidence and mortality

continue to rise so treatment options for HCC can be divided into three categories surgical options non-surgical options and systemic therapy patients are screened diagnosed and treated accordingly of

these three options interventional radiologists offer the non-surgical approach which include trans arterial embolisation percutaneous ethanol injection radiofrequency ablation and microwave ablation so I want to talk

about the child pu classification the child pious core consists of five clinical measures and is used to assess the prognosis of liver disease and cirrhosis including the required strength of treatment and necessity of

liver transplant the child piu score was originally developed in 1973 to predict surgical outcomes in patients presenting with bleeding esophageal varices today it continues to provide a forecast of the increased increasing severity of

your liver disease and you're expected survival rate the Chao few score is determined by scoring five clinical measures of liver disease the five clinical measures are total bilirubin serum albumin prothrombin time ascites

and hepatic encephalopathy once scores are available in each of the five clinical measures all scores are added and the result is a child piu score their interpretation of the clinical measure is as follows so Class A would

be five to six points lease liver disease with one to five year survival weight at 95 percent Class B seven to nine points moderately severe liver disease one to five year survival rate at seventy five percent and Class C ten

to fifteen points most severe liver disease one to five year survival rate at fifty percent so which child pew scores do I our patients fall into for a research with the CPC and the majority of the HCC child pew scores a and B

seven with the survival rate of one to five years for 95% the best outcomes are achieved when patients are carefully selected for each treatment option regardless of the treatment approach

patients with HCC require a multidisciplinary approach to care to ensure optimal outcomes what we refer to as tumor board tumor board are meetings where specialists from surgery medical oncology radiation oncology

interventional radiology and others collaboratively review a patient's condition and determine the best treatment plan through this multidisciplinary approach patients have access to a diverse team of experts

instead of relying on a single opinion each specialty will have unique contributions to ensure optimal long term outcomes for patients with HCC so there are various algorithms for HCC treatment I actually have one on top of

the other there just to show you that if you're interested in the process you can look it up it's there's a few out there all right so how are the patients selected for treatment like I said tumor board and moving on now to the surgical

options there are two surgical options liver resection and liver transplant surgical resection is currently considered to be the definitive treatment for HCC and the only one that offers the prospect of cure or at least

long-term survival however most patients have unresectable disease at presentation because of poor liver function the overall resect ability rate for HCC is only 10 to 25 percent and even among those who undergo surgical

resection with curative intent there is a recurrence rate of it to 80% at five years post resection survival rates are in the range of 80 to 92% at one year sixty-one to 86 three years and 41 to 74 at five years

the most common sight of post resection recurrence is a remaining liver for patients who are not surgically resectable liver transplant is the only other potentially curative option virtually all patients who are

considered for liver transplant are unresectable because of the degree of underlying liver dysfunction rather than tumor extent down staging using local regional therapies can also be used to increase eligibility for orthotopic

liver transplant while on the transplant list patients disease progress and meeting criteria gets complicated so patients on the transplant list are and do get some other therapies

which I will later discuss so we're surgical resection is not possible for poor liver function liver transplant is a treatment of choice prior to 2008 no systemic therapy was available that demonstrated an improvement in survival

with the publication of two randomized placebo-controlled phase 3 trials the oral multi targeted tyrosine kinase inhibitor sorafenib has become the new standard of treatment for advanced HCC with an increased median survival from

seven point nine months and the placebo group to ten point seven months in the treatment group systemic therapy can be difficult to tolerate because of the side effects dose reduction or treatment interruption is often needed

despite the side-effects treatment is recommended and to be continued into a progression of the tumor is demonstrated the majority of diagnosed patients with HCC present with advanced disease oral therapy has taken two pills twice daily

equaling 400 milligrams B ID so interventional radiology it's like surgery only magic so I I always think about this when patients come in and pre-op beam and they think they're having surgery you know it's well a lot

of benefits to ir what we're doing so interventional radiology is where the magic happens and non-surgical approach procedures are performed percutaneous local ablation include ethanol injection and radiofrequency ablation microwave

ablation is utilized both percutaneously and intraoperatively and lastly there is trans arterial embolisation which depending on the embolization agent can either be chemo bland or radioisotopes percutaneous ethanol injection known as

Pei has a long track record and is very effective in destroying HCC tumors that are less than or equal to 2 centimeters in diameter performed under percutaneous ultrasound guidance a needle is placed into the tumor and absolute alcohol is

injected over recent years radiofrequency ablation referred to as RFA has largely replaced Pei at most centres RFA's also performed percutaneously advancing a specially designed electrode into the tumor and

applying radiofrequency energy to generate a zone of thermal destruction that encompasses the tumor and a 1 centimeter margarine surrounding liver RFA is thus preferable to ethanol injection for patients with solitary

tumors 2 to 4 centimeters in size for tumors smaller than 4 centimeters RFA can achieve initial complete response rates of over 90% in microwave ablation MWA microwaves are created from the needle to create small

regionals regions of heat the heat destroy the liver cancer cells RFA and microwave are effective treatment options for patients who might have difficulty with surgery or those whose tumors are less than one and a half inch

in diameter the success rate for completely eliminating small liver tumors is greater than 85% so can I get a show of hands from the audience on who what facilities are doing chemo embolization everybody pretty much are

you guys doing them next to the gentleman yeah okay so this is gonna be a boring review here alright so trans arterial embolisation a minimally invasive procedure performed to restrict to tumors blood supply it is performed

by advancing and angiography catheter into the branches of the hepatic artery supplying the tumor and injecting an agent mixed with orally contrast followed by a cluding agent known as beads the beads which range from 100 to

300 micrometers in diameter are carried by the circulation into the terminal hepatic arterioles where they lodge and include the vessel resulting in the schema tumor necrosis the procedure is done using moderate sedation patients

are monitored for 23 hours or less for pain and post embolization syndrome trans arterial chemo embolization thus is where the chemo therapeutic agent mixed with beads is injected to the tumor

these particles both blocked the blood supply and induced cytotoxicity attacking the tumor in several ways taste is the treatment of choice when the tumor is greater than four centimeters or there are multiple

lesions within the liver taste takes advantage of the fact that while the liver is refused by both the portal vein and the hepatic artery HCC survives its blood supply almost entirely hepatic artery tastes has been shown to

prolong survival in patients with intermediate stage HCC and objective responses were observed in the majority of patients tear trans arterial radioembolisation is a form of catheter directed internal radiation that

delivers small microspheres with Radio isotopes directly into the tumor y9t microspheres are administered and a procedure similar to taste the procedure has been shown to be safe and effective in cirrhotic patients with HCC the side

effects are usually well title tolerated one major advantage of y9t over taste is that it is indicated in the case of portal vein neoplastic thrombosis while taste traditionally has been considered a contraindication all right so there's

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