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Introduction to Establishing Periprocedural Screening Guidelines to reduce bleeding risk associated with Image-Guided Theraputic and Diagnostic Procedures | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
Introduction to Establishing Periprocedural Screening Guidelines to reduce bleeding risk associated with Image-Guided Theraputic and Diagnostic Procedures | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
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Normal Bleeding | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
Normal Bleeding | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
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Practice Guidelines | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
Practice Guidelines | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
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What Makes a Procedure Low Risk? | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
What Makes a Procedure Low Risk? | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
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What Makes a Procedure Moderate/High Risk? | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
What Makes a Procedure Moderate/High Risk? | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
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How We Established our Practice Guidelines | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
How We Established our Practice Guidelines | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
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General Screening Criteria (specific to bleeding risk) | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
General Screening Criteria (specific to bleeding risk) | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
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Combining Guidelines with What You Know | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
Combining Guidelines with What You Know | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
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Summary of Bleeding RIsks | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
Summary of Bleeding RIsks | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
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Q&A Bleeding Risks | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
Q&A Bleeding Risks | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
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Transcript

I'm Nikki Jensen Nicole is what my mother calls me but that's alright thank you all for joining us today I am the clinical resource nas I work in a clinical nurse specialist position I graduated in May so I'll finally be called the clinical nurse specialist

after I passed my boards in nonvascular radiology so at Mayo Clinic Rochester we are kind of split up between I are in our IR practice where we have non vascular procedural Center CT MRI ultrasound guided procedures we'll go

over a list of our standard perform procedures as well as our neuro interventional and vascular interventional practice so Kerri and I work in the non vascular so we do not do any neuro interventional or vascular

vascular interventional procedures so these guidelines are going to focus on your LR CT or ultrasound guided procedures how many of you went to the combined session this morning great this is going to be an overview because what

we saw presented there really reiterates what we are have brought into our practice but then we're also going to share how we created nursing guidelines and how we rolled that into our practice this is Carrie Carrie is a staff nurse

in our department I worked as a staff nurse for seven years prior to this position I've been in this position now for four years and really enjoy it I do want to give a little shout-out to Carrie and I presented or sorry we

published an article in the June 28th volume 37 issue - that really coincides with our presentation today so I would encourage you to read that publication and then you'll get additional information on how we did this yes all

right we have nothing to disclose unfortunately or fortunately right so the purpose of this presentation is to help you all understand the importance of creating reviewing the literature

understanding your for one your coagulation casket as well cascade as well as anticoagulants that are out there or new up-and-coming medications and understanding that yes it's very important to establish and create these

guidelines so that within your practice you don't have differing radiologists that have differing opinions if you're working with doctor so-and-so today you need to worry about these labs if you're working with you know dr. Johnson

tomorrow he doesn't care about the labs we did this to help standardize that to help reduce the amount of questions our nurses have how many times we're interrupting our radiologists but then also we need to take into consideration

the importance of the patients and their different disease processes and we'll be going over that too so it's nice to have established guidelines but then also we need to take into consideration why patients are on certain medications this

here is our list of objectives I'm not going to read them for you you can all read them and we've provided you all with handouts too but really we want to just help kind of explain mechanism of actions and different medications and

how we established our guidelines this here is where Kari and I come from full disclosure we do have snow on the ground so these pictures were not taken before we came we are really enjoying this nice warm weather but for those of you who

are not familiar with the history of Mayo Clinic in Rochester who we have a hundred and fifty plus year tradition of implementing evidence-based care to assure the needs of our patient come first we are divided up into one

downtown campus but we have three different main areas so we have our st. Mary's Hospital this is where Kerry is based out of this is this houses most all of our ICUs as well as most all of our inpatients so we do a lot of

inpatients but we also see outpatients in this hospital Rochester Methodist Hospital this is where our he mock patients typically are we do have one ICU within Hospital as well but then right here my

office is right there this is our Mayo downtown campus so this is where most of our patients come for outside procedures or outpatient diagnostic imaging exams this here is the group that I'm part of the clinical nursing specialist group

within our clinical nursing specialist group there are 77 of us there are five like myself clinical resources as we have not graduated as of yet I'm right there in the middle w

that work in over 70 ambulatory areas in 58 inpatient areas we also support some areas in our Arizona and Florida campuses and then we have Mayo Clinic Health System hospitals that are scattered throughout Iowa

Wisconsin in Minnesota as well I am the only one in radiology across all of our

campuses okay so now here's more of an introduction to our practice and to help you understand why we had to create these guidelines to use so within our

practice we have approximately 22 CT scanners we'll have 25 by the end of the year we have 40 M our scanners one of them being a 7 Tesla scanner currently we are doing head and knees on that scanner but yes it's open to clinical

patients it was really great bringing that in last May and then we have 50 ultrasound scanners we work amongst 78 CT technologists they work within the diagnostic imaging and procedural practice so our CT technologists go back

and forth 115 M our technologists and 90 scenographer 's we also have a hundred and sixty-five frontline nursing staff that work across our practice and 165 radiologists and procedure lists so understanding that concept is why we

needed to standardize this we could not accept our nurses to memorize what types of hold times or what types of medications each physician was concerned about here are some of the common types of

procedures note we do lots of other things but these are our big hitters this is what Kari and I are involved in most every day deep organ biopsies your liver kidneys pancreas drain placements intra-abdominal biopsies bone lung

biopsies breast biopsies superficial biopsies paracentesis thoracentesis basically any fluid aspirations fine needle aspiration superficial drains and chest tube placements and now I'll have

Kerry go into kind of a refresher from

this morning for you all this is a video from a liver biopsy and let's just start that no we actually don't know how to play this from the clicker okay

so this is just a short clip to show normal bleeding everybody bleeds and all the procedures that we do involve placing needle in the patient so we are going to have some amount of bleeding and it can range from seconds to minutes

and hopefully it's a fairly minimal amount of blood loss typically what happens is the needle is inserted into the patient the body detects the injury clotting mechanisms are activated hemostasis is restored which sounds

pretty simple but as you may remember from this morning there are a lot of different mechanisms involved that make that happen and we wanted to just provide a brief overview for those of us that have been out of nursing school for

a little while so we thought it would be helpful to start with just a brief generalized overview the first step obviously is the endothelial injury platelet plug forms the coagulation cascade starts we get a clot and then we

have the Ambo thrombotic control mechanisms and the fibrinolysis in our practice we're really just concerned with the first two we really just want to make sure that the patient has the ability to clot so here's a fairly

simplified version of the coagulation cascade the factors are the Roman numerals and to keep it simple we've just included a few of them so we have a wound occurring the endothelial cells release the tissue factor which combines

with some factors we get factor 10 release produces thrombin and eventually fibrin we also have this amplification loop that's happening at the same time so we need some of these factors we need the thrombin for this all to work

so at this point we have thrombin being generated by the pathways more being created by the amplification process and that thrombin then binds to these platelet para scepters up here and that initiates cofactors assembling on the

platelets which makes them sticky causing them to adhere to the site of injury when the platelets are activated we have the adenosine diphosphate molecule or ADP that's also binding to some receptors specifically I didn't

include the p2y on this but the p2 y 12 which then eventually winds up activating this molecule down here that molecule is normally this complex I should say is normally folded over but when the platelet is activated it

unfolds and it allows the fibrinogen to bind and then that secures the platelets to each other so with the medications that we run into in our in our practice one of the ones that you learned about this morning where the direct factor 10

inhibitors we typically see Xarelto and Eliquis the most in our practice and as you can see by the red stop signs there are two places that these inhibitors work here and here they bind to the thrombin while the while the drug is

circulating in the blood which essentially removes that factor Xa from the equation if we don't get thrombin we don't get a thrombus we don't have a plat no these things do have a relatively short half-life and in our

practice we do not monitor these with routine labs the direct thrombin inhibitors Pradaxa is the one that we see the most work one step further down the chain these are actually interfering with the power receptors so they bind to

those and that prevents the platelet activation and aggregation these can be monitored with a PTT although research tells us that it doesn't necessarily correlate with the actual levels circulating in the

blood and the different methods of sampling aren't consistent so this is not something that we routinely monitor with labs in our practice as well and I do have agents and clinical trials on here they were in trials I believe at

the time we started doing this research but as we learned this morning some of them are currently available and these do have a short half-life so their effect is relatively limited and they are reversible so the inhibitors that

work on this p2y twelve receptor are actually binding to that receptor and this is irreversible so this is going to affect the playlet for the life of the platelet seven to ten days and as we learned this morning there's a certain

amount of turnover happening all the time so there are always new platelets being produced so if we stop this we don't necessarily need to hold it for the entire seven to ten days but it is something that's going to take a while

for the patient's body to overcome and the thing that we wanted you to note about this this is an inhibitor it's an inhibitory effect so it's not necessarily captured that accurately by lab values the platelets are still there

they just don't work as well and so you can do a platelet count but it's not going to show you how well those platelets are functioning so again this is another medication that doesn't really get captured with lab values

sorry little operator error here on the remote control so the Cox inhibitors aspirin is the one that we're probably most familiar with same kind of thing aspirin is permanently affecting the platelet over its lifespan of seven to

ten days the ibuprofen the naproxen or Aleve the effect is much more limited for these medications so we're going to hold these again these are medication that will not necessarily be accurately reflected by a lab value so in our

practice we rely on oral confirmation of the last dose we literally ask the patient when was your last dose of advil when was your last dose of aspirin and we can compare it to our procedural guidelines

we also talked about these a little bit this morning we have the vitamin K antagonists warfarin is the one that you hear about you also hear about it called to mannan by the other name the liver is producing these clotting factors which

are reliant on a reaction that happens with vitamin K these things actually work by interfering with the vitamin K cycle now if you put more vitamin K in this reaction can still happen or if we add FFP that already has these factors

in it the patient has the ability to clot so this is reversible we can also choose to not reverse patients that are on warfarin Nikhil talked a little bit about the bridging that we sometimes do with patients that are on warfarin but

this is one that we still encounter pretty frequently and typically it is monitored with the pt/inr and we are currently screening for angiogenesis inhibitors in our practice these are used to treat different kinds of cancer

the one that we are primarily concerned with is the imbruvica the mechanism of action how this causes bleeding isn't fully understood but it's thought that since these inhibit the development of endothelial cells those cells aren't

available to release the factors needed to start the clotting cascade and especially if these are used in conjunction with anti platelets or anticoagulation they can really have a it can really have an effect on the

patient's bleeding risk and they can also cause thrombocytopenia thank you

now that you all have an overview and a refresher of nursing school and how these medications work in our body I want to now go over our practice

guidelines and the considerations that we take into place so as you know I'm not going to go over into detail the patient populations that are prescribed these meds but kind of knowing that these are the

patients that we see in our practice that for example are on your direct direct vector 10a inhibitors patients with afib or artificial valves or patients with a clock er sorry a factor v clotting disorder these oral direct

thrombin inhibitors patients with coronary artery thrombosis or patients who are at risk for hit in even patients with percutaneous coronary intervention or even for prophylaxis purposes your p2 y12 inhibitors or your platelet

inhibitors are your cabbage patients or your patients with coronary artery disease or if your patients have had a TI AR and mi continued your Cox inhibitors rheumatoid arthritis patients osteoarthritis vitamin K antagonists a

fib heart failure patients who have had heart failure mechanical valves placed pulmonary embolism or DVT patients and then your angiogenesis inhibitors kind of like Kerry said these are newer to our practice these are things that we

had just recently really kind of get caught up with these cancer agents because there really aren't any monitoring factors for these and there is not a lot of established literature out there knowing that granted caring I

did our literature review almost two years ago now so 18 months ago there is a lot more literature and obviously we learned things this morning so our guidelines are reviewed on a by yearly basis so we will be reviewing these too

so there is more literature out there for these thank goodness so now we want to kind of go into two hold or not to hold these medications so knowing that we have these guidelines and we'll be sharing you with you the tables that

tell us hold for five days for example hold for seven days some of these medications depending on why the patient is taking them are not safe to hold so some of the articles that we reviewed showed that for sure there's absolutely

an identified risk with holding aspirin for example a case study found that a patient was taking aspirin for coronary artery disease and had an MI that was associated with holding aspirin for a

radiology procedure they found that this happened in 2% of patients so 11 of 475 patients that sounds small number but in our practice we do about 400 procedures in a week so that would be 11 patients in one week that would have had possibly

an adverse reaction to holding their aspirin and then your Cox inhibitors or your NSAIDs as Carrie already mentioned it's just really important to know that some of those the Cox inhibitors have no platelet effects and then your NSAIDs

can be helped because their platelet function is normalized within 24 to 48 hours Worf Roman coumadin so depending on the procedure type and we'll go into that to here where we have low risk versus moderate to high risk

we do recommend occasionally holding warfarin however we need to verify why the patient is absolutely on their warfarin and if bridging is an option because as you learn bridging is not always on the most appropriate thing for

your patient so when patients on warfarin and they do not have any lab values available that's when you really need to step outside of guidelines and talk with your radiologists your procedure list and potentially have a

physician to physician discussion to determine what's best for a particular patient this just kind of goes into your adp inhibitors and plavix a few of the studies that we showed 50 are sorry 63 patients who took Plex within five days

of their putt biopsy they found that there was of those one bleeding complication during a lung biopsy so minimal so that's kind of why we have created our guidelines the way we did and here's just more information

regarding your direct thrombin inhibitors as cari alluded to products is something that we see very commonly in our practice and then your direct vector 10a inhibitors this is what we found in the literature

all right so in our practice what defines our low-risk bleeding procedures very simple in our lower breast relieving procedures bleeding is easily detectable at the time of the procedure so we have identified those procedures

as our paracentesis thoracentesis our simple superficial aspirations or fine needle aspiration x' as well as any of our msk aspirations superficial biopsies meaning within the body wall or superficial to

the neck our deep neck biopsies are considered a high risk bleeding procedure and then any of our superficial drain placements most of these are done under ultrasound guidance in our practice and to define these what

does the literature say so we took a lot of our recommendations from SAR we do identify the same procedures that SAR does as low risk versus moderate to high risk and then we found within the literature that lab values recommended

our inr for patients with known or suspected impaired liver function as they went over again this morning or for patients who are on warfarin so any patients who are in warfarin whether it's a low risk or high risk bleeding

procedure we do recommend in our practice in INR for these patients

and then completely the opposite or I should say a little bit more severe we discuss what makes high risk bleeding procedures are moderate so weak lumped

moderate to high risk we made we made this decision in our practice to not have three different categories to help reduce confusion and because when we examined the hold times or the medications to be concerned between

moderate to high risk they are very similar and we did not want to put in broad ranges for example a lot of the literature out there you'll notice that they'll say hold five to seven days we've determined we will say seven days

is our recommendation because five to seven that's a huge gap and how how are our nurses supposed to make that decision when they're reviewing a patient's chart so that is why we've combined the moderate and high risk and

how we've identified those procedures are they're obviously more difficult to detect bleeding and in intervention for these are more invasive a lot of these we are doing under CT guidance some of them are deep organ biopsies are done

under ultrasound guidance and the literature says much of the same as it does for the low-risk and again I show that we are agreeing with si are on their categories and then the INR we do recommend having an INR for all of our

moderate to high risk bleeding procedures we do recommend considering or discussing with the radiologist correcting any values greater than one point five and then known noting that platelets and hematocrit are not always

accurate in transfusion is oftentimes recommended for platelets under 50 but there really is no recommended threshold out there regarding hematocrit and right here important we do not recommend aspirin being held for any of our

patients unless the patient is simply taking aspirin as a prophylactic type case in which we do see in our older population patients will come in and just say they started taking aspirin there's really no no provider

prescribing that or directing them to take that aspirin so how did we

establish our guidelines this was something this was a question that we got when we did publish our journal article because you'll see when you do

see our guidelines we are not 100% in alignment with SAR that is because we used SAR in a detailed literature review and examined both of those sources but then we also have our own homegrown radiology database our nurses are

instrumental in collecting this data every biopsy patient we collect their medication list as well as their current lab values we've been doing this since 2002 and we currently have over 50 000 patients within that database so we pull

from that database to identify what is best what trends are we seeing what medications are we seeing that are causing issue in our practice so we're taking from our own clinical expertise and then we also have a great panel

within Mayo Clinic it's called ask me Oh expert this panel is made up of multiple physicians we have physicians from Department of Laboratory Medicine physicians from our anticoagulation practices we have our liver physicians

can need lots of different doctors we have two radiologists that also sit on that committee so it's a combined specialty panel so we take we took into consideration all of these factors to establish our guidelines our nurses use

these guidelines when they are performing pre-procedure phone calls so I love to the presentation yesterday from Johns Hopkins I believe where they're doing pre procedure phone calls but often times a whole week before we

don't have that yet but I would love to get to that point but right now our nurses are doing pre procedure phone calls within a few days prior to a patient's procedure and we are going through these guidelines to identify

what medication or risk factors these patients have and we're alerting our radiologists to see if there's any type of considerations that we may need to take if for example a patient has not stopped warfarin and

then they also look for if within our guidelines the patient needs lab values we determine if there's lot values ordered or if they have any within the medical record we want them within 30 days except for if the patient has known

or suspected liver disease we do want them more recently within 14 days or if a patient's on chemotherapy or one of those anti antagonists this is something I really need to stress to our nurses and I think I've gotten the point across

to you that these are guidelines only clinical decisions are made by the supervising radiologist so we've we've put this right in all of our guidelines in that yes these are guidelines that we can use those nurses to help triage our

patients and move and streamline our assessment process but sometimes it does further critical thinking and then discussion you want to go into what you

guys do so when we do our screening phone calls and our pre screens before

the actual procedure there's a few factors that we look at for the patients with blood pressure the patient needs to be vitally stable before we do a procedure there may be a slightly increased risk of bleeding for kidney

biopsy if patients are hypertensive although it hasn't been noted to be statistically significant in the literature so we are always aware of patients being hypertensive we do want them to be taking their medications the

day of the procedure we also do a full medication reconciliation with the patient making sure that we're checking on any anti platelets anticoagulant medications and we have a list of our hold times that we use for a reference

we already discussed for those of you who are at this session this morning the issue of liver disease is it stable liver disease they may have adequate he stasis even though their INR is not within the normal range and so we

recommend a stable INR of less than 2.5 for those patients and in our practice a lot of the providers are going away from correcting the INR s for our patients we also screen for hematological disorders do they have some known condition that

makes them more likely to bleed or conversely more likely to clot and that may factor into whether or not anticoagulation can be held do they have a current diagnosis of cancer are they going to be getting one of those

angiogenesis inhibitors might they have thrombocytopenia and we just do a brief review of the patient's chart before we call them to kind of look for those diagnoses do they have a history of bleeding especially if they have no one

platelet dysfunction you know a known history of bleeding can be a reliable predictor of bleeding risk for some patients and do they have a cardiac or a neurological history as we learned this morning patients that have recently had

a cardiac stent placed we can't just say yeah stop your plavix hold off 5 days it'll be fine that could be a very serious risk to the patient did they recently have a stroke have they had a PE why are they on their anticoagulation

if they're on it so we really need to be aware of the whole patient and having that pre-screening phone call with them can allow our nurses to figure out a lot of these problems and then alert the radiologists and try and troubleshoot

before the patient walks in the door and says yeah I took my warfarin this morning I'm all ready for my liver biopsy the radiologists don't like that much in it you know it's really a bad thing for our high volume area to have

that happen and this is just another chart of our oh did I get mixed up here you guys are gonna fire me from running this clicker there we go so the whole times are again based on the half-life and the mechanism of action and this is

pretty similar to what you saw in the the presentation earlier today and specifically that imbruvica that's something that we alert the radiologists who they have a discussion with the patient decide is this something that we

want to continue with and I will say that in our practice with the volume and the the level of acuity of our patients I think that a lot of our providers are fairly comfortable with a certain level of risk because that's just who our

patient population is you know we have a very large hospital two large hospitals and very sick patients so that's something that we you know some of them are more comfortable than others but it's a risk-benefit thing that they have

to decide on themselves with the patient obviously all right so here are our

guidelines so what I did when I created these was try to really simplify them Terry and I have given all this information to our staff nurses we've

this was a two and a half year project we took in feedback from our radiologists obviously went on off of their clinical best practice and their clinical experience this table here is a table for our low-risk bleeding

procedures I've already given you the list but within our guidelines I've created hot links where they can just click on whatever procedure they're doing in it it'll bring them to the appropriate table but as you can see for

our lowest bleeding procedures we currently we are no longer really gathering much from our patients we've deemed that it is safe for these patients to have this procedure this is also in the journal article so I would

recommend that you guys read that here's our moderate to high risk procedure again like I shared earlier we've decided to combine moderate to high risk versus having two separate tables so this one is where we also need to take

into consideration our patients and their disease processes and why they're on certain medications but this allows for our nurses to look at this list for these patients and determine how we triage this patient next it allows for

these pre procedure phone calls and our pre procedure screenings assessments that we're doing to be more expedited

and I'm gonna let Carrie go over a case study with you all we printed and gave you one of those and this is just gonna

kind of really show you the importance of yes let's have established guidelines to help guide nursing practice but then let's also take into consideration what we know so I'll just give you all a minute to look over the the patient I'm

not going to read this all to you what's the journal was 28 to the right is right here June 2018 volume 37 number 237 number 2 June 2018 and it's bolded in our reference side - so here's the time for audience feedback if you are a

nurse and you saw this patient what are some things that might concern you about them heading into a procedure there's microphone if anybody wants it or you can just call out liver dysfunction when we were looking

at this patient and this is you know an actual patient that I saw doing a workup and said hmm this is a really complex patient what are we going to do with this person they are having a lowest procedure as Nicky points out so that is

good to note in this patient was actually admitted following a stroke while anticoagulation was being held for another low-risk procedure so that's definitely something that caught our attention and we looked at our lab

values again the INR pretty normal they were taking lovenox at home but they're currently in the hospital they're on IV heparin and a lot of our procedures come up at the last minute so this is it's not uncommon

for us to show up in the morning have half of our day filled and have cases added as the day goes on and I would imagine that's pretty much the standard for most of you so and they wanted this today this was more of a therapeutic

procedure but they really did want it for the patient so we got out our nursing guideline we looked at what medications are they on what's their history what does our guideline tell us and I've included the low-risk procedure

and it tells us IV heparin hold for four hours so normally the nurse would call the floor and say can you have a discussion with your service would you know can they hold the heparin per our procedural guidelines in this case we

didn't feel like it was a good idea to have that nurse to nurse conversation this is a case where we went directly to the radiologist and said here's the patient here's what our guidelines tell us could you please call the service and

have a conversation with them and they did they talked about the risks and benefits you know in our practice we do occasionally do procedures with IV heparin running it's been known to happen it's definitely not preferred but

again it's that risk benefit decision in this case the service felt it would be okay to hold the heparin for four hours the radiologist agreed that they would be okay with and so the heparin was turned off the

flora nurse called us when they turned it off we verified it in the medical record transport order was put in the patient was brought down at exactly four hours and the procedure was performed successfully the patient was returned

directly to the floor and the heparin restarted but we just picked this one as just an interesting patient to look at because it does show we have these guidelines they encourage nurses to look at these things while we're screening

patients but we also need to think critically and say you know does this warrant a little bit of extra consideration should the radiologist and the service have this conversation or is the service managing the patient going

to do what our recommendations say so we do run into this kind of thing quite often and they did say at the session this morning nurses want a guideline but there's no cookbook for these patients and I think that emphasizes that we can

make all the screening guidelines in the world they're very helpful for streamlining triaging patients getting patients in but ultimately we're going to have a lot of these multidisciplinary conversations where radiologists are

talking to the service that's managing the patient and flora nurses radiology nurses everybody is getting involved in the conversation so it's really kind of a collaborative approach even though we do have these guidelines they don't

apply for every situation

all right we're gonna go into summary I wanted to leave room for questions too so we'll summarize everything up for you all but as you know and I love I love radiology and I know you all do too

that's why you're here and that's why we stick with radiology but as you know our imaging image-guided therapeutic and diagnostic procedural practices are growing and we're partnering especially at our institution I'm sure at yours but

I can't speak to yours we're partnering more closely with Hema and we're doing a lot more things with our patients so our practices are growing and it's very important to create some type of guidelines something that our nurses can

refer to to help really minimize some questions that we may have when we're triaging or screening our patients and it's very important for us as nurses to understand the mechanism of action of medications that our patients are on as

well as what happens to our patients when they are undergoing biopsies and then something that was kind of hard for our practice to kind of grip is that it's not always safe to hold medications we may have the guideline that says we

should hold warfarin or we should hold that aspirin but it's not always safe for patients sometimes it puts them at an increased risk and then that we we have linked our procedures to low or moderate and high risk bleeding

guidelines and that it's important to still use critical thinking and understand the difference between low and high risk procedures and then knowing that it's really important that these standardized guidelines have been

implemented to allow for our nurses to have something to refer to to reduce questions asked by our nurses and then it helps to allow a streamline workflow for a high throughput area this is an acknowledgment to our team members

these were great individuals that helped to us when we were first looking at this Celeste and Aaron are two of our nurses that really helped me dig into our own data and pull out what medications we seen

were linked and correlated to a high-risk bleeding procedure dr. Thomas Atwell dr. John Knutson in dr. John Schmidt's all three of them chair within our department CT in ultrasound operations dr. John Schmidt says our

chair of our contrast and medication and moderate sedation committee so we worked really closely with those three to determine what their recommendations were and what they have pulled from their discussions with members of SAR

so we had to get that in there because unfortunately they couldn't come here with us today all right so now we're

going to open it up to any talks or questions great great question great question so

her question was do we share these guidelines with her inpatient nursing staff yes I did a clinical Grand Rounds where we kind of over viewed but no expecting them to remember this and understand it no but it is available

online within our my own Mayo Clinic intranet for them to refer to but then that also comes down to our nurses calling the flora nurse - because they're really screening these patients and then calling and having that

conversation with our floor nurses and then just prior to Kerri and I travelling here these guidelines are also being shared across our enterprise for enterprise conversion so Arizona Florida and Rochester the referring

clinician yes yes yes so that's why okay so that's why it's really important to have that physician to physician disgusting yes our radiologists are not putting through these orders to hold these medications

that's a very good point to make that is where our radiologists will be calling the ordering clinician and determining hey I really strongly encourage you to hold this medication on this patient if you disagree what are your objections

and then they discuss the plan going forward from there our microphone isn't working hello yes yep so you you want to take that yes we do have like I shared I would love to be

doing these phone calls a week in advance we have not gotten that far but that's something that we're looking to you can explain the company we run into this on a daily basis yes and you know with all the health systems and we have

so many people ordering these procedures that don't understand what we do what our coagulation guidelines are a lot of our physicians in the Health System and other parts of the clinic have access to that ask Mayo expert which which does

follow that guideline so it is available but a lot of times we are finding patients that are getting added a day or two before and the bulk of our pre procedure phone calls are done the night before the procedure so when that

happens and we call the patient and they say oh yeah I just had a stent placed in my Hospital in Montana a week ago then that's the point at which we have to turn it over to the radiologist and say can you look into this and we have

fellows often that will look into that the night before and the procedure may be rescheduled it may be delayed or it you know been depending on the patient condition they may have that risk-benefit conversation and decide to

proceed yes so yes and no so in our practice a lot of these patients are all patients strictly outpatients so a lot of these patients are not even sent to an AM admits they come directly to radiology

they report right to our desk but with the phone calls the we what we use epic how many of you guys use epic so scheduling we do have scheduling triage is yes so our scheduling triage right now

because I can't give them all these guidelines we've put in our big hitters we have them ask are you taking any new blood thinning medications do you take warfarin that's the one medication that we do call out so yes sorry

yep I've misunderstood what you're asking it does yeah yeah you know your exact yep so good point and when we first rolled these out I sat down with our scheduling supervisor and we updated all of our

triage is to reflect because we did have it in all of our procedures and then we removed it from some [Music] they need it for the semen we say Menards

yeah okay and you [Music] yeah mm-hm yeah it's so good what world

you know and I would like to add so what we're trying to do now that we have a Peck we've just recently rolled it out so we're trying to optimize it trying to create BPA so that it can pull these medications and give an alert to the

ordering clinicians boat and then you run into alert fatigue and things like that but that's that's our next step in this problem we do where you know we're fortunate so that yeah okay do you want to we share that we share

that tub so her question was when you have when you do identify in a patient's chart when you're doing a review that the patient is on one of these medications who has that conversation with the ordering clinician and we're a

little bit spoiled in that we typically have residents and fellows and so our staff radiologists might not want to have that conversation but we do tend to have a fellow who sort of triage is all those problems both in the late

afternoon and in the morning before we get started so they can call providers and have those conversations and if it's at the point where the patient is already there then it's too late for that conversation so then that becomes a

you know supervising radiologist and patient discussion all right yes I uh I'm full disclosure we do not get all of our pre-procedure phone calls done we do the best we can and we prioritize it and oftentimes we're doing

it up until eight o'clock at night and we are pretty selective about who we call we're not if we have a lot of cases we're not going to call low risk procedures we're not gonna call the repeat biopsies if they've had a biopsy

in the last few months yeah repeat procedure call and and and so that's where we differ - so in our practice we do not use moderate sedation for any of our ultrasound guided procedures or even our deep organ

biopsies shouldn't say any we yeah right never say any board's question but uh very rarely do we local only no blocks yeah but those are for our low-risk bleeding procedures or our deep organ kidney

livers pinks oh yeah oh all that's in there patient appointment guide also it's mailed to them but then also we have a Mayo Clinic app so they can just click where their

appointment is and the map we're spoiled because there's big infrastructure but if any of you guys have any questions please feel free to reach out to a carrier myself again it's in your handouts so thank you all

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