Chapters
Medical Therapy Options | Management of Patients with Acute & Chronic PE
Medical Therapy Options | Management of Patients with Acute & Chronic PE
chapterdrugsexpensivemedicationsNoneoptionspulmonarystudiedvasodilation
Dashboard Drill Down Report | Innovation and Application of Real Time Nursing Dashboards
Dashboard Drill Down Report | Innovation and Application of Real Time Nursing Dashboards
chaptercomponentdatademonstratedinterpretNonenursingpatientreporttimeline
Overview of Diagnostic Errors | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
Overview of Diagnostic Errors | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
academyadversechapterdiagnosticeducationalerrorhospitalizationsmedicineNonenursespatientproceduralsafety
Organizational Strategy | Innovation and Application of Real Time Nursing Dashboards
Organizational Strategy | Innovation and Application of Real Time Nursing Dashboards
alignchapterdailydartmouthdatadevelopfrontleadersmeaningfulmetricsNoneorganizationalorganizationspacemakerspatientsradiologyseniorstaffstrategiesstrategytranslate
Education Strategies to Reduce Human Errors | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
Education Strategies to Reduce Human Errors | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
activeaneurysmangiographybostcerebralchapterchecklistclotconcurrentcontraindicationcontraindicationsdistallyembolizedguidelinehemorrhageheparinisismilligramNonepatientphysiciansstandardstentstentingstentsstrategiestemplatetherapeuticthrombolysistpa
Building the Radiology Nurse Dashboard | Innovation and Application of Real Time Nursing Dashboards
Building the Radiology Nurse Dashboard | Innovation and Application of Real Time Nursing Dashboards
accomplishalignbuildbuiltcapturecategorychaptercovercreatedatadesigneddisplayeddocumentationengagementintentjeannejourneymeasuresmetricsmodalitiesmultipleNonenursenursesnursingpendingproductradiologyrealrelevantselectedstaffingsystemteamunderstandworkflow
Human Factors Engineering- What is it? | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
Human Factors Engineering- What is it? | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
anesthesiaanesthesiologistanesthesiologychapterdisciplineengineeringfactorshealthcarehumanislandmonitorNonenuclearpatient
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
atwellchaptercloselyguidelineshemamedicationsmoderateNonenursespartneringpatientspracticesradiologyriskworkflow
Pre-procedure Assessment | Procedural Sedation: An Education Review
Pre-procedure Assessment | Procedural Sedation: An Education Review
abnormalitiesadverseairwayanesthesiaanesthesiologistapneaauscultationcervicalchaptercomorbiditiescopddiseaseedemaejectionfractionhabitushemodynamicallylitersmedicationsneckneurologicNonepatientpatientsphysiologicproceduralpulmonaryrenalsedationsleepslidesspinestatus
Q&A- Success, Case Add-Ons | Innovation and Application of Real Time Nursing Dashboards
Q&A- Success, Case Add-Ons | Innovation and Application of Real Time Nursing Dashboards
capacitychapterdecisionsdrivenjourneymodalitiesNonenursesnursingobjectivestartedteamworktechsutilization
Factors Contributing to Hypoventilation | Respiratory Compromise: Use of Capnography During Procedural Sedation
Factors Contributing to Hypoventilation | Respiratory Compromise: Use of Capnography During Procedural Sedation
airwayapneabenzodiazepinebreathchapterchroniccolonoscopycomorbiditieselevatedfentanylhypoventilationhypoxiamedicationsmonitormuscleNonenonspecificobstructiveopioidsoximetryoxycodonepainpatencypatientpatientsrespiratoryriskscoressedationsleepundiagnosed
Key Patient Safety Influencers | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
Key Patient Safety Influencers | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
advancingahrqaimsawarenesscarechaptercultureeventshealthhealthcareNonepatientphysicianpracticingqualityreportreportingsafetystandards
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
alertbiopsiescallcallschapterclinicclinicianFellowsguidelinesmayomedicationmedicationsNonepatientpatientsphysicianprocedureproceduresradiologistradiologistsschedulingtriage
The Dashboard Implementation | Innovation and Application of Real Time Nursing Dashboards
The Dashboard Implementation | Innovation and Application of Real Time Nursing Dashboards
applyappointmentassessingbufferchaptercheckedinterpretlatemetricsminuteminutesmodelNonenursenursesnursingpatientpatientspendingproceduralradiologyscheduledtimetotalutilizationworkup
What are the Options? | Uterine Artery Embolization The Good, The Bad, The Ugly
What are the Options? | Uterine Artery Embolization The Good, The Bad, The Ugly
chapterconsequencecontinuingdiseaseembolizationfibroidhydronephrosishysterectomymyomectomyNoneoptionspatientsperiodstransvaginal
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
activatedaspirinbindbindingbleedingcapturedcascadecellschaptercirculatingclotclottingcoagulationdoseendothelialfactorfactorsinhibitorsinjuryinterferinglabslearnedmechanismsmedicationmedicationsmoleculemonitoredneedleNoneoverviewpatientplateletplateletspracticereceptorreceptorsreleasereversiblethrombintrialstypicallyvitaminwarfarin
Pharmacology- Opiods | Procedural Sedation: An Education Review
Pharmacology- Opiods | Procedural Sedation: An Education Review
acutechapterdrugelderlyfentanylinactiveinhibitorsintubationmedicationsmetabolitesmetabolizedmilligrammorphinenarcanNonenurseopioidpatientspharmacokineticpotentproteinrenalresidentversed
Overview of Respiratory Compromise | Respiratory Compromise: Use of Capnography During Procedural Sedation
Overview of Respiratory Compromise | Respiratory Compromise: Use of Capnography During Procedural Sedation
apneaappropriatelyatelectasiscellschaptercompromisedepressiondioxideepisodicetiologyfactorskrebsmedicationsmonitormonitoredmonitoringNoneopioidsoxygenoxygenationpatientsphysiologicprocessesrespiratorysedationventilation
The Anatomy of Errors in Health Care | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
The Anatomy of Errors in Health Care | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
anatomybedsidebluntchaptereventfactorshealthcareleadersNoneorganizationpatientsafetysharpsystem
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
anticoagulantscampuschapterclinicclinicalcoagulationgraduatedguidedguidelineshospitalinpatientinpatientsinterventionallabsmayomedicationsneuroNonenonvascularnursenursingpatientspracticeproceduresradiologistsradiologyrochesterspecialistultrasoundvascular
Pharmacology- Antagonists & Additional Medications | Procedural Sedation: An Education Review
Pharmacology- Antagonists & Additional Medications | Procedural Sedation: An Education Review
anesthesiologistanesthesiologistsbenzodiazepinesbolusbradycardiachapterdosedrugflumazenilguidelineshypotensioninfusionmedicationsmehtamonitornarcanNoneopioidpotentpropofolreversalsedationversed
Why is the Capnography Reading Abnormal- Physiology | Respiratory Compromise: Use of Capnography During Procedural Sedation
Why is the Capnography Reading Abnormal- Physiology | Respiratory Compromise: Use of Capnography During Procedural Sedation
abnormalairwaybaselinebloodcarboncardiacchapterdioxidefeverhealthykrebslunglungsmetabolismmismatchmonitorNonenormalpatientpatientsperfusionphysiologyproducingpulmonarysedationshunttrendsvaluesventilation
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
afibarteryaspirinbiopsybridgingchaptercoronarycoumadindirectDVTembolismguidelinesholdholdinginhibitorsknowingliteraturemedicationsmedsNonensaidsosteoarthritispatientpatientspercutaneousphysicianplateletplavixpracticeprocedureprophylaxisreviewedriskthrombinvalvesvectorwarfarin
Theories on Accident Causation | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
Theories on Accident Causation | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
anatomychapterdefensesfailuresinterventionalmistakesNoneoccurringpatientvisible
Dashboard Component- Nursing Case Volume per Hour | Innovation and Application of Real Time Nursing Dashboards
Dashboard Component- Nursing Case Volume per Hour | Innovation and Application of Real Time Nursing Dashboards
callschaptercolorcoupledatadocumentationinterpretMRINonenursenursingpacemakerspendingphonevolumeworkup
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
acuityalertanticoagulantanticoagulationbiopsybleedingcardiacchapterchartdysfunctionhematologicalhistoryhypertensivelivermedicationsNonepatientpatientsplavixprocedureprovidersradiologistsriskstablestentthrombocytopenia
Just Culture Concept | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
Just Culture Concept | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
adversebedsidechaptercultureengageerrorseventfearharmleadershipmedicationNonenursenursespatientreportsupportiveunlabeledvials
Human Factors That Reduce Situational Awareness | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
Human Factors That Reduce Situational Awareness | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
awarenessbluntchaptercommunicationfactorshumaninstrumentMRINoneoverloadpatientpreciselytaskversus
Transcript

real briefly about medical therapy options there are a lot of different

options with a lot of fancy medications that have been studied the problem with these medications these patients are gonna be on them life long and their disease is never gonna get better it's just gonna get maintained so there are

multiple different classes of drugs and basically what they're all doing is causing vasodilation of the pulmonary arteries so a couple drugs that we I think many of us know viagra is on their sildenafil believe it or not that has

more than one use and this is one of the main uses pulmonary hypertension there are other drugs that were created specifically for them that are prostaglandins or guanylate cyclase stimulators which basically cause

vasodilation many of these have been studied for for many years and they're very expensive as much as $1 000 a day so that's pretty expensive insurance does cover them but they're expensive drugs with potential

side effects so I'm gonna finish off the

so last is a drill down report so as Tommy mentioned we've kept the dashboard simple for the nurses to easily interpret the data so we really we needed it to be like a quick visual

however there are times when nurses might need more context in detail behind what they are seeing in the dashboard this shows a drill down report as you can see behind each dashboard component that we just spoke about that can

provide some additional details so example this report shows the actual time stamps and it's a little squished because it's a long thing but these are the actual time stamps and that's how we generated the data for the scorecard and

this is a great tool during huddle time to quickly investigate and answer more specific questions about the patient timeline so remember when the first one I showed you with the red boxes and for like nine minutes late or whatever

well with this drill down you're able to kind of see whether the patient got there on time so where they the patient might came thirty minutes before their appointment said a sixty or what was the holdup and you can actually see was it

the nursing that's running behind or or the physician or whatever so it really helps to drill it down so you can get to this drill down report by clicking on this icon on each dashboard component so this was the nurse casing buffer time

indicator and as you can see there's a couple of tabs up here and this right here can get you down to this drill down report one things I wanted to mention is that this report can also be manipulated to run data historically and over larger

timeframes it's sort of how Tommy got the information for the scorecards by using this drill down report and then she could also pull it for like I said daily Huddle's at the end of the day we can look at a particular case and say

why was it late and what do we r and so really fixing things in real time so this completes the formal part of our presentation on our journey to create meaningful nursing dashboards at D H and just to review our objectives so we hope

that you were able to make the connection that Chris spoke about between the different leadership boxes and the importance of lining across aligning across different levels of the organization remember

strategy is ineffective if you can't be rolled down to the front lines second Tommy discussed and we demonstrated how data is an important part of driving high quality patient care and that behind every number there is a story and

every story there is a number thirdly we hope you learn some useful ideas for building and designing your own nursing dashboard and lastly we demonstrated the practical application of the dashboard for the frontline staff using the look

interpret apply and assess model so

thank you for joining me this morning as we talk about patient safety and risk management we're gonna touch on a number of different things but for starters can I see how many of bedside or procedural room nurses CTM our procedural room excellent okay all right okay all right

any leaders charge nurses directors awesome all right by chance are there any physicians in the crowd all right okay cool welcome thanks again for coming okay so just to note I have no financial or educational conflicts of

interests all right so today we're going to be talking about and discussing some key patient safety influencers in health care we're going to take a look at something that's called human factors engineering we're going to look at

educational and global human error reduction strategies and we're going to take a look at the just culture concept and its impact on patient safety Event Reporting so according to some statistics from this year for patient

safety week which was March 10th through March 16th so just a few days ago there are about that occur due to patient due to adverse events and 10 to 20% just to highlight a

few 10 to 20% during medical examiner cases they find that there have been some misdiagnosis during that so arriving at an accurate diagnosis is fundamental to the practice of medicine yet according to the 2015 Institute of

Medicine report most patients will experience at least one diagnostic err in their lifetime this report will also note that diagnostic errors contribute to about 10% of patient deaths and account for up

to 17% of adverse events during hospitalizations so currently we have about 41% of Americans who say that they've experienced a medical error either in their own care or that of a loved one or a friend and the National

Academy of Medicine and just a word about the National Academy of Medicine the IOM in July of 2015 changed their name to the National Academy of Medicine so this statistic comes post July of 2015 and they're

suggesting that 5% of US adults who seek care in outpatient settings experience a diagnostic error so that's the reason why we're here today so when we're

there are some issues that impact human performance and you can substitute issues with human human factors and these factors that some of these factors

are present before an action takes place and those are fatigue stress and boredom dehydration and hunger there are some factors that are directly related to allowing us to make a decision and those are perception our memory our attention

our reasoning and our judgment and lastly there are factors that directly influence how a decision is executed and that's communication and the ability for us to carry out the intended action so a little bit about fatigue fatigue is the

easiest human factor to overcome but it's also probably the greatest human factor that interferes with our performance and our personality so fatigue affects us by reducing our decision making ability it prolongs

response time it increases lapses in attention and negatively affects short-term memory lessons the ability to multitask and it increases irritability moodiness depression and it also decreases our ability to communicate

part of what's built into us our mental shortcuts so we rely on these shortcuts in reasoning to minimize delay or cost or anxiety in our clinical performance you can imagine that if you everytime you had to run a fluid through an IV

line if you had to think back to when you were in nursing school about how you had to open the package take the line out straighten it out put it into the into the solution and run it through if you had to think about those steps every

time you did something or if you're in an ir procedure room if you had to think about every time you go to set up your patient if you had to actually think about those steps it would take you a very long time so we rely on mental

shortcuts however there are some things in our human condition our human factors that interfere with that and this is cognitive bias and hindsight bias so cognitive bias is a mistake in reasoning or evaluation and it often occurs as a

result of holding on to preferences or beliefs regardless of information in front of us and it's actually an attempt of our brain to simplify information processing hindsight bias works similarly but it calls upon experiences

that we've had in our past and we use them moving forward and what that does is it gives us cognitive dispositions to respond and those are jumping to conclusions seeing what's already expected whether it's actually there or

not it's a bias towards action versus non action so you may want to do something but really the better patient safety may be to wait and collect more information so that non action and assess get more of an assessment and

then there's an overconfidence bias these cognitive factors can contribute to diagnostic error in about 74 percent of cases

looking for risk we find it in about 11 areas and they're in an order that

represents those that are highest in risk for lawsuits obstetrics tends to be the highest because of its dollar value so there are nurses that work and they're called Life Care planners and they use different charts and statistics

from the government and from the CDC that work on disease processes and birth errors and they come up with a dollar amount for the care of that child and that tends to be for the life that's predicted from government charts and

that's why those end up being in the millions of dollars and as we look we see that radiology is actually eighth on this list and the the driver behind this is the missed or heirs in diagnosis

so before we get into the dashboards which I know you're all interested in

hearing about I'm going to talk a little bit about organizational strategy and how it really does align with our frontline workers so we all know that senior leaders have a responsibility to create a vision and a strategy for our

organizations they do this using benchmarks cost margins revenue in order to position our organizations to deliver high-quality care but also to position ourselves in ever-growing markets which I'm sure you're all aware of so as

organizational leaders develop these strategies for future development it is really important that the front line that the mid-level leaders are able to take these strategies and translate them down to the front lines so when you read

a story or you watch a movie you just assume that the cast of characters and the plot are going to follow along and if they don't we lose interest or we become disengaged so in this case can you trace the CEOs sorry can you trace

the CEOs vision for his strategy and how he asks the mid-level leaders to take down to the front line probably not and this is what all organizations struggle with because we know that the whole is always greater than the sum of all the

parts so now we're going to show you some boxes and these boxes represent the front line the mid-level and the senior leaders let's have a show of hands today for how many of you in the audience consider yourself to be frontline staff

do we have any mid-level leaders great how about senior leaders great well today our dashboard presentation is going to mostly apply to the frontline staff so we know that when organizations build strategies and they ask our

mid-level leaders to take them down to the frontline staff that sometimes the translation of that information creates chaos and disruption at the front lines and an example of that is at Dartmouth our senior leaders had a strategy for

improving access for care for an underserved population of patients that had pacemakers and needed MRIs Fordyce diagnostic studies we felt we could take the volume so we embarked on imaging patients with pacemakers and what we

found is that the number of patients that had pacemakers was outpacing the resources that we had at the frontline and this created chaos and it made the good intention of the strategy lost on the frontline nurses so it's really

important that we not only take strategy down to the frontline but that the mid-level leaders take the reaction of the staff and how it affected their work back to the senior leaders so in 2013 at Dartmouth we began our journey to bridge

this gap and we did some process improvement projects and we soon found that the data that we were presenting wasn't really accepted or understood or trusted by the staff that we were working with we discovered

that at the front lines that sometimes perception is not always reality so our job was to help the staff objectively understand how to work on a daily basis how their work on a daily basis impacted our organizational strategy in 2015

you'll see we went live with the radiant product that epic has for radiology and when I began looking at the reporting metrics that epic presented I saw that it didn't really translate into radiology language and it really didn't

translate into nursing language at all so we needed some metrics and we needed a way to be able to give the nurses meaningful actionable information that they would be able to work on and that we could really turn them into

data-driven problem solvers so this is when I engaged with Thome our quality specialist and I asked her to help us develop a strategy for how we could empower the staff to become more data-driven problem solvers what we

decided was that we first had to build build competencies and understanding around data and how Thome decided to do this was to develop these monthly scorecards the scorecards our performance scorecards that the leaders

in the organization in our department can use to kind of measure their success so we first met with the leaders in each modality and this was the radiology directors it was our technologists lead our nurse's leads and Thome sat down and

said what would be meaningful for you to understand so that you can talk to your staff about the business that you are running so this is an example of one of the scorecards that Thome built and at the same time we decided that we would

align our organizational strategies and our department strategies with these scorecards this is an example of an IR scorecard and you'll see that they chose quality and safety operational excellence and

sustainability this was a way to look at what their monthly volumes were and when we were asking them maybe to move that needle a little bit and give us some more and they felt maybe that they couldn't because the staff was saying

that they were too busy we could show them that the utilization in one of their rooms was 65% and maybe there was indeed some opportunity to move that number a little bit after we were successful with the scorecards and we

felt we had built the competency on the department the section director level Thome began working on dashboards and these are real-time metrics that our frontline staff can use every day to see how well they're processing their

patients through our system we also developed daily Huddle's where they take these dashboards the charge tech nurse tech the radiologists staff if they're interested and we talk about what went well what maybe didn't go so well we

talked about action items opportunities for improvement and maybe some projects that we could start around things that they identify that are impacting their workflow so now I'm gonna turn this over to Tommy who's gonna talk to you about

how she used that data to get us to our dashboards thank you Chris all right so

strategies so some things that we have

in place right now our peer review Grand Rounds CPOE this is one of my one of my favorite process improvements is is making the right thing the easiest thing and you do that through standardization of processes so that's standard work so

that's your order sets that's the things pop-ups although you don't want to get into pop-up fatigue but pop-ups help our providers for little gentle reminders to guide them to what's right for the patient and to cover everything that we

need we need to cover to ensure the safety of our patient so recently in the fall of last year we had a TPA administration err that occurred it involved a 69 year old patient who two weeks prior had had some stenting in her

right SFA she presented to our clinic when our clinics with some heaviness in her leg and some pain and when she was looked at from an ultrasound standpoint it was determined that her stents were from Bost so she was immediately taken

to the cath lab and it was after angiography did indeed show that there was clot inside these stents they did start catheter directed thrombolysis in the cath lab they also did started concurrent heparin often oftentimes done

with CDT what's usual for our institution is that we have templates that pull in the active problem list for a patient in this case the active problem list or a templated HMP was not used had they

used the template at agent p they would have found that the second active problem on this patients list was a cerebral aneurysm so some physicians will tell you some ir docs will tell you that's an absolute

contra contraindication for TPA however the SI r actually lists it as a relative contraindication so usually we're used to when you when you start a final Isis case you know you're gonna be coming in every 24 hours to check in

that patient in this case we started the the CDT on a Thursday the intent was to bring her back on Monday the heparin many ir nurses will know that we will run it at a low rate usually 500 units an hour and we keep the patient sub-sub

therapeutic on their PTT although current literature will show you that concurrent heparin can also be nurse managed keeping the patient therapeutic in their PTT which is what was done in this case so what ended up the the

course progression of this patient was that so remember we started on Thursday on Saturday she regained her distal pulses in her right leg no imaging Sunday she lost her DP pulse it was thought that it was part of a piece of

that clot that was in the the stent had embolized distally so they made the decision with the performing physicians they consulted him to increase the TPA that was at one milligram an hour to 2 milligrams by Sunday afternoon the

patient had an altered mental status she went to the CT scan which showed a large cerebral hemorrhage they ain't we intubated to protect her airway and by Monday we were compassionately excavating her because

she me became bred brain-dead so in the law there's something that's called the but for argument so the argument can be made that this patient would not have died but for the TPA that we gave her in a condition that she should not have had

TPA for namely that aneurysm so this shows how standard work can be very important in our care of our patients and how standard work drives us down the right way making the easiest thing the safest thing so since that time

we've had a process improvement group that we've established an order set specifically for use and thrombolysis from a peripheral standpoint and then also put together a guideline that was not in place so it's some of that Swiss

cheese that just kind of we didn't have a care set we didn't have a guideline you know we didn't use our template so all those holes lined up and we ended up with a very serious patient safety event so global human air reduction strategies

oops sorry let's go back these are listed in a weaker two stronger and some of what we're using in that case is some checklists so we developed a checklist that needs to be done to cover the

absolute contraindications as well as the relative and it's embedded in the Ulta place order that the physician has to review that checklist for those contraindications and also there to receive a phone call from pharmacy

just to double-check and make sure that they have indeed done that that it's not somebody just checking it off so we have a verbal backup sorry so the just

so what is it like to be a nurse in radiology all four of these boxes represent the essential part of radiology nursing workload and staffing speaks to how our rit nurses cover all seven modalities in radiology in a

variety of functions these functions include but are not limited to sedation IV therapy triage recovery education and emotional support for our patients regarding staffing this requires deploying nurses in multiple locations

at one time to ensure that the patients are receiving the best care at the right time for us the challenge was how do we adequately deploy the staff to multiple areas while being efficient fiscally responsible but continue to provide

compassionate care the next box epic which is our electronic medical record centers around orders and documentation as Cris mentioned earlier in 2015 we went live with radiant and epic plugin specific

for radiology workflow the radiant functionality was exam specific and less patient flow specific this presented a problem for nurses who cover patients and all modalities and had more documentation requirements than the

technologist did and the last box engagement as we know is so important our nurses felt like they were getting pulled in multiple directions and often time misunderstood by the other modalities and radiology that really are

just focused on their modality and it risks nursing job satisfaction and increased our burnout rate right so as Jeannie described to you that was the current state that our nurses we're facing and as we designed or created the

dashboards we had to understand how we could create meaningful metrics for the nurses to address all these different issues that they were facing our nurses and dartmouth-hitchcock radiology did not just cover interventional radiology

so they were covering MRI CT fluoro so they were all over at the department and it was really hard to capture all of that work and really help them understand how to align their staffing to cover all these multiple modalities

and that also made it difficult for engagement sometimes as they interacted with different staff across the department so we have to consider all of this on top of the complexity with documentation in our EMR system we had

to combine all of these factors as we designed the dashboard so fortunately for us we did not follow Dilbert's boss's philosophy we had much more intent international intent as we design our dashboards so when it came to build

in the radiology nurse dashboard if we could sort of break down the steps we took we would go over these three categories the first category is identifying what measures were relevant for the nurses given the current

situation that they were facing the second category was where that information lived and how we could pull this in to the dashboards meaningfully and the last is how that data needs to be

displayed on the dashboard so going to our first category here which is what measures are relevant we have two main goals the first goal was to select measures that could help our nurses monitor their performance in real-time

so again this was part of our journey around competency building and sustainability across the department and we knew that for our frontline staff including our nurses they were not used to looking at data especially data in

real-time to make decisions and a lot of their description about their day was very variable and really driven by perception of what they were feeling at any given moment so our objective or our goal around monitoring real time for

performance was to create an objective understanding across the board around how the day went so if someone said that they were really busy what did that actually mean so trying to make sure everyone speak in the same language

using data and objectively understanding their performance the second goal around our measures was to help the nurses be more proactive around decision making so as a part of this journey we wanted our frontline

staff to be better problem solvers and be empowered to make decisions around their workflow and so we wanted the measures to be relevant around helping them make more proactive decisions to be more efficient around their daily work

to the left here as an example of some of the metrics that we selected Gina will go into more details around to the dashboard but that's just a real quick snap short of some of the metrics that we selected and a lot of those metrics

are showing pending work for our nurses and a lot of what that does for them is decide how they can align their staffing on a daily basis to accomplish a lot of the pending work that they have so that's just an example of some of the

measures that we selected to accomplish those goals so moving on to the second category here which is where the information lives as Chris and Jeannie both mentioned and I'll mention it again because it was a real pain when we went

live with radiance in 2015 it wasn't great for nursing it didn't capture a lot of the nursing work accurately and because our nurses covered so many different modalities it was difficult for them to see all of their work in one

place in a way that made sense so part of our journey or one of the biggest things as we built the dashboard was to create nurse resources within radiance that helped us accurately capture all of the nursing work and described it in a

way that was easy for them to understand and differentiate between the different kinds of work that they did in radiology and then we am partnered with epic to participate in a cojito project cojito is a branch of epic which builds

dashboards almond does analytic reporting so this was a paid engagement where we told them what we wanted and they had their analytic team built and designed the dashboards within the epic system the engagement took about 12

weeks to complete and that was not just for the nursing dashboard we had about 17 different dashboards that we were building across radiology and so all that entire engagement took about 12 weeks to complete and so that was how we

partnered or that was where we partnered with the epic cojito team to actually build those dashboards within the EMR system and then finally in our process of building the radiology nursing dashboard we had to figure out how the

data needs to be displayed so again we were dealing with frontline nurses who are not used to looking at data and at first we're really opposed to looking at it because they didn't really understand what it meant to them and so we had to

make sure that the data was simple and easy for them to to understand especially in real time for the dashboards it has to be something that they would look at it would be visually appealing and they could really get

enough context in real time to make a decision around their workflow so we had to juggle all of these different pieces as we built and design our radiology nurse dashboard and in a minute you will go over what that actually looked like

when we're done but before that I wanted to show you a prototype of what we started with as we embarked on the cojito project so this is just a PowerPoint template or design that we shared with the Epico hero

team when we started this was our way of sharing or showing our vision of what we wanted on the dashboard we knew that there were a team of analytic people who didn't necessarily understand our operations of workflow so we wanted to

make it easy for them to understand what we needed and we also had to do some shadowing and training in real time with the analytics team as they embarked on this project to build our dashboard but of course when we presented this to them

we knew that our actual product would would the result of the final product would be constrained by what they had in the system so for example they did not have as many callers in their color palette to create a dashboard and so as

Jeanne goes over our final product you might not see as many beautiful colors in there that was their upgrading to more colors and that was great but we knew that as we move forward we would have to be restricted by what they

actually had in the system for a final product or outlook but I just wanted to share this just to give you if you're thinking of embarking on their journey to build dashboards you can start simple just create a wait just have a way to

share your vision with the with whoever the Analects analytics team is that is built in the dashboard you don't have to know what it would look like exactly on the system itself so now Jeanne is gonna walk you through

our actual dashboards and how we apply them in real time thanks to me

get into human factors engineering so James riesen who were going to talk a little bit more about said we can't change the human condition but we can change the conditions under which humans work and this is the discipline that is

human factors engineering so it's a discipline that takes into account human strength and limitations in the design of interactive systems that involve people tools and technology and work environments to ensure safety most

notably or most recently they were involved in the restructuring or re-engineering of anesthesiology machines so you may remember a time when anesthesiology machines didn't even have a monitor a

patient monitor on him they were just the machine and they had the bellows on them on top that would go with the patient respirations so since that time they've been written a re-engineered to include a patient monitor further

reengineering took in human factors which is is the human condition and I'm going to get into some of those human factors a little bit later but we they took a look at the monitor to make it more clear and intuitive for the

anesthesiologist they also took a look at the alarms of these anesthesia machines to make sure that they were accurate and had a better range to prevent alarm fatigue and then lastly they put in some automation into those

machines human factors engineering is also used outside of healthcare in aviation automobiles so the backup camera that we enjoy at our cars that came from human factors engineering and also a Three Mile Island they used human

factors engineering when they looked at that accident that nuclear accident that took place those many years ago and they used what they learned from Three Mile Island to design much safer patients say sorry nuclear power plants so it's it's

not only used in healthcare but throughout all of our industries so

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

includes an interview of the patient abnormalities of major organ systems like cardiac status do they have a reduced ejection fraction do they have coronary artery disease I want to know

if they have an EF of 10% because if they become hemodynamically unstable and I want to give them fluids I'm not going to bolus a patient with a very low ejection fraction with two liters of fluid you're gonna cause

pulmonary edema and you're going to worsen the situation renal status is huge a lot of our patients are renal e impaired and that can affect the way that they clear the sedation medications that we're giving pulmonary status do

they have COPD asthma or sleep apnea sleep apnea is major in procedural sedation neurologic status do they have a history of seizures endocrine status hyper or hypo metabolism of medications can occur if they have a thyroid

disorder we want to know about adverse experiences with sedation in the past do they have a history of a difficult airway for us at NYU if they have been already been identified as a difficult airway that automatically means we're

doing the procedure with anesthesia current medications potential drug interactions is very important we'll go over that a few slides drug allergies and herbal supplements that they're taking tobacco alcohol or

substance use and frequent or repeated exposure to sedation agents is just going to increase their tolerance of the medications physical exam vital signs auscultation of heart and lungs and then their airway assessment sorry excuse me

do they have any Strider snoring or sleep apnea advanced RA they're gonna have a hard time tilting their neck back if they have cervical spine disease or they have rheumatoid arthritis chromosomal abnormalities like

trisomy 21 patients with Down syndrome can have an enlarged tongue that can impair your ability to manually ventilate them if respiratory depression wants to occur body habitus if they have significant obesity especially of the

head and neck areas and head and neck limited neck extension short neck decreased ornamental distance which is basically just looking at how far back they can tilt their head any neck mass and then again cervical spine disease or

trauma do they have a c-spine collar are they on c-spine precautions that's not a patient we're going to be able to manipulate their airway and then mouth opening we do use Mallampati and I'll review

that in a couple of slides so the AFC classification is a categorization of the patient's physiologic status that can be helpful in predicting operative risk it is recommended by the AFA that if a patient is an Asaf or that that

should prompt an evaluation by an anesthesiologist I will tell you at NYU we will still get procedural sedation to some patients who are in Asaf or but we like to identify it ahead of time because if they have significant

comorbidities that will potentially increase their likely hurt likelihood of having an adverse outcome we then have a lower threshold for activating a rapid response or a code if something was to happen if we got concerned about

something so the airway assessment is

we're happy to open up the floor for questions you want to use it maybe a mic for them yeah sorry oh let's use a microphone then everyone can hear Thanks

can you hear me on this one yeah so I think your question was how successful were we thank you for this presentation so I used to be six feet tall so I will tell you that the journey was very difficult and it's not for the faint of

heart it takes a lot of people to really make this happen and as I mentioned in 2013 we were working with the value Institute and that's where I grabbed Thome from I stole her shamelessly and you know we did some projects and I'll

say the first few were not successful and what we learned from that and I mentioned in my speech is that they don't understand data unless you put it and you present it in a way that's meaningful and that was hard for us and

and so yes it was hard so my so my point is that that this is really incredible and how I would use this and based on your experience how helpful was this to to increase your efficiency and for the nurses to actually look at this and say

oh my god you know this is what we have to meet and we're not meeting it so yeah so I will tell you and the journey was real I mean the perseverance was I mean it really was driven by Chris and Tomi they didn't give up and we met like even

when we started with the scorecards we met weekly with all of the supervisors in all modalities because we didn't just do this for IR Nursing we did it for all modalities and it was it was really hard in the beginning because I kind of felt

like that's where we talked about stories and numbers you know and I I talked about Nursing being a very story driven you know the frontline nurses want to help for their patients and when you show them numbers they start telling

you that all you care about is your volume and your data and you're just going to keep driving us until we get driven down into the ground and so it's no honestly and so it was how do we make that connection and I think to your

question we started with the scorecards as those were less impactful to the frontline staff but once we started using the dashboards and we just we slowly like rolled it out we started with

Huddle's first and we had like the charge check and the charge nurse talked about it and then other nurses and text would be around in the core and they would sort of listen in and maybe chime in about why a case was laid and what

have you and so we started doing the Huddle's and then once we rolled out the dashboards now we have actually a big screen up that runs the dashboard is visual um in the core of the IR a suite and it's really great we have there

actually it's so funny we have them an on-time start like glitter posters so it's on your like it gets posted on the outside of your door and everyone's involved before it was like the techs were much more driven about getting the

cases on time the nurses were less but now we've really actually the teamwork the competition of it and the teamwork it's hilarious I love seeing it they're like yes I've got like all my cases were on time today and they ran like room to

like a clock and so it's it's been very good and they've really utilized that the other thing I love is you know the work up stuff so after the day sort of you know winds down and they're trying to figure out like what were cups they

have to do or whatever I watched the charger she'll put up on there and say like we need you know we need to get this done or whatever so it's really helping to to show them like what work they still have to do so no

one's just standing around going I'm not sure what I'm supposed to do now you know the other thing I'll mention though that was important to getting there was so we took all the lead techs in every modality we call them education

coordinators in our modalities and Tommy did classroom work with them so they would come they would come every two weeks and sit in a classroom and Tommy would speak specifically to the reporting metrics and what it meant and

it did two things it not only taught them how to read data it also engaged them with each other and we cross kind of crossed the modalities where they were siloed in their work before it really built some teams among the

technologists and the nurses and Tommy spent a lot of time teaching them and it it it was very impactful so I would I would absolutely recommend that you have to have some kind of classroom work for this do you want

I think she um great presentation like this is quite inspiring you know it's really nice to see that you've able to build this up in accomplished and everything you did my question is more on a Don cases so when

it's scheduled its predictable you can try and work work things so that you hit everything on target but how do you deal with a Don cases cuz we I feel like in our in our area ninety percent of the cases I add ons so how do you how have

you been dealing with it are important and that was a lot of why we started this journey because a lot of what we would get is oh we have another add-on case and now the world and the sky's fallen over it was a lot of that

reaction to everything that was thrown on a frontline staff so I'll start from the scorecard let me start from the scorecards so on the scorecards we have the utilization numbers which shows how much of our

capacity were using and that was the first step for the team or for everyone to start to understand how much work can we actually do and how much of it have we and how much over that we utilize in today so if we are at a 50 or 60 percent

utilization we're not really at a high capacity utilization rate but then who still had frontline staff who thought add-ons were very chaotic and so it wasn't necessarily about the volume of work it was how we were managing it so

starting to break it down in this way helped everyone start to understand okay maybe it's not that we're doing too much it's how are we managing what we have so that was why the numbers were important to set that objective level of

understanding in the first place and then when it comes to the stat to the dashboards which is more frontline information because they have so we don't have the I our interventional radiology dashboard here

on that dashboard we can see the utilization in each room so we can see how much how much capacity there is to actually manage to add on more cases into each room so that's something that when they make decisions on add-ons they

look at each room and say what is the utilization currently do we have enough time to actually add on one or two more cases and then as Jeanne showed you in the nursing on the nursing dashboard with the caseload by hour of day they

can make decisions around what time of day is the best time to add on this case because we see we already have five at 8:00 a.m. maybe we should add this case on at 1:00 p.m. so it's really helping people make more objective objective

decisions around the add-ons or around their workload vs. reacting to everything that comes up so you talked

if we had less blame we'd have more patient event reporting and from there

we can do more to look at our systems in our organizations and really affect patient care it helps so increased reporting helps to prevent future patient harm it provides an indication of human and system performance so again

we're working on the system not the person it guides performance improvement and it also provides an opportunity to identify risks it also provides a culture of safety so we go from blaming the equipment and the other person to

looking at owning some of our own air and then ultimately when we know that we have not followed a policy as we should have because we know that we're gonna our leadership is going to look at that and find out why we didn't do what we

were supposed to according to policy sometimes those policies are written by people who aren't at the bedside or they're so old that they're not up-to-date they don't have best practice in them and so we'd need to be conscious

of those so you know every three years we're supposed to be updating our policies and procedures and that includes our departmental ones too and we need to be looking at best practice and listening to our staff to really

prevent patient safety errors so if you look at your system design and behavioral choices if you spend 80% of your son time there you could really reduce your human errors in your adverse events that's

what a just culture and a culture of safety brings you but in order to do that you have to have organizational trust so management needs to be trusted management needs to trust the staff and staff needs to trust management so all

that is cyclic elana just culture you would have that so how do we get there I

some of the contributing factors to hypoventilation well certainly will we give sedation we give you know a benzodiazepine we give other medications we combine those with opioids right that

decreases our responsiveness to elevated co2 levels but we also have muscle relaxation certainly in patients with obstructive sleep apnea history undiagnosed or undiagnosed they lose their muscle tone in the airway patency

kind of diminishes very very quickly and they also have a decreased response to hypoxia all again creating that perfect storm of an adverse event waiting to happen and even patients that have don't normally have obstructive sleep apnea

can have it under our sedation so the key signs and symptoms you know clearly respiratory rate is one that we monitor but we also want to monitor the quality of ventilation right one look at patients tidal volumes and how much

they're expiring with each breath we want to look at their sedation scores whether you're using the rasp score or any of the other standardized scores spo2 less than 90 for at least thirty seconds that's pretty significant

hypoxia especially if somebody's on oxygen and hopefully you would detect somebody who's deteriorating much earlier than that but that certainly would be a terminal sign before they became bradycardic and you were pulling

out the code card but certainly using capnography you could tell breath by breath right instantaneous looking at those waveforms and look to see if the patient is not only taking enough breaths per minute but are they

taking quality ones so let's look at a little bit of a case study here we're gonna kind of look at this case study throughout so this is Jane Doe she's 39 years old she's being worked up for a nonspecific abdominal pain they've ruled

her out for gallbladder issues and appendicitis and they want to do an upper endoscopy in a colonoscopy she's treated with chronic pain medications gabapentin and oxycodone and she's had some surgeries in the past no allergies

to anything so concerns with this patient so what risk factors does this Jane Doe have for during for at risk for respiratory compromise during sedation possibility of undiagnosed OSA be a bio t mass index obesity high risk

comorbidities medical condition or advanced age there's more than one right answer so just make mental note here and these are the correct ones so she potentially has obstructive sleep apnea she does have an elevated BMI and she

has medical conditions she's sick acutely and she has pain medications as part of her chronic therapy so now let's look into solutions so again with our case studies after we give her some versed and a hundred Mike's of fentanyl

the patient develops the following pattern on the monitor so what should your first step be in this scenario nothing because her pulse oximetry is normal be stimulate the patient to take a deep breath perform jaw thrust and

place patient at a sniffing position to open the airway give a reversal agent or D intubate the patient good B you guys are all anesthetists now we have a bunch of positions open at Yale if you're

so let's talk about a few of our key

patient safety influencers so the Institute of Medicine came out with a landmark report called to err is human building a better health system in that report they stated that health care in the u.s. is not as safe as it could be

or should be and at that time there was forty forty four thousand two ninety eight thousand deaths occurring due to medical air so they defined medical error as the failure of a planned action to be completed as intended or the use

of a wrong plan to achieve an aim the number comes as the IOM quantified through a 1984 Harvard patient care survey they also estimated that the reporting of preventable adverse events is underreported so these are our near

misses these are our opportunities for change and those are underreported but it did support a collaborative relationship with quality improvement and just to note that not all errors result in death okay so as you could

well imagine this report met much scrutiny and had a lot of comments that came out the next one the next report is the future of nursing leading change in advancing health that came out in 2010 and in that the IOM called for nurses to

take an active role in preventing patient safety airs and they asked us to step up by practicing to the fullest extent of our education and training and from that time we saw a lot of academic advancement to terminal degrees so a lot

of doctorates that's the DNP started coming out we saw a lot of nurses advancing from Associates to be a sin BSN to masters etc to terminal degree our next influencer is the Committee on quality

healthcare in America and they had a project in which they focused on the 2001 IOM report which is crossing the quality chiasm a new health system for the 21st century now a lot of things came out of this report with regards to

the the government latched on to this one with some of our advances for quality care they have some specific objectives for improving healthcare delivery specifically they were revolved around six aims and those six aims were

safe effective patient-centered timely efficient and the equitable provision of healthcare but they noted that the biggest challenge was going to be establishing a culture that encourages reporting of events of our patient

safety events that may result in either actual or potential harm to our patients or others and this culture was actually known as the just culture which is we're gonna discuss a little bit more a little further next we have the National

Patient Safety Foundation so they're a central voice for patient safety they also promoted the patient safety awareness week that I spoke about so the NP SF enhances patient safety awareness through educational programs

research project grants awareness campaigns and they encourage patient and family involvement so many of your organizations may have patient or family liaison groups that work with your nursing administration or your

leadership in looking at the patient care experience during a hospital stay and how that can be improved and also as it relates to patient safety events that may happen are near misses those may also be

discussed with patients and family to get their perspective on how we could improve the Leapfrog Group is a coalition of for fortune 500 companies and what they do is they they buy health care but in order to get them to buy

your health care you have to meet certain patient safety standards that they have such as CPOE so computer physician order entry also ICU physician ICU physician staffing standards sorry and there are a number of other things

that they look at as well the agency for Healthcare Research and quality the AHRQ this is where a patient safety and risk we live here there's a lot of a lot of the patient safety event systems reporting systems that are out there are

based on AHRQ fundamentals that way we can benchmark across the nation on how we're doing with patient safety events so the last one is the Joint Commission and they have their national patient safety standards all right we're gonna

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

so are you ready here's the final project product tada that's what our d-h radiology nursing dashboard looks like today so as Tommy mentioned the goal of

our dashboard is to help the frontline objectively understand their performance and be proactive about making decisions to help their run day their day run smoothly all of these metrics on the dashboard work together to achieve those

goals so for example at the top right here the procedural workup pending and calls pending help to see the volume of pending workup and phone calls that need to be completed over the next few days another exam

well here on the bottom left the nursing case volume that's another it helps us to sort of see the different levels of nursing resources needed by hours of the day the dashboard is not just for nurse managers and for supervisors but for the

frontline users as well we had to teach your nurses how to use this information in real time what we have learned that by using actual data to drive decision-making nurses are able to deliver patient care more consistently

and in compliance with standard practice they are also able to manage variation and optimize utilization of resources the dashboard proves to be an easy tool to apply and capture meaningful metrics around the radiology nursing workflow

this is the framework we use to educate the frontline nurses on the real-time application of the dashboards we broke it down into four simple steps look so looking at the data interpret and gain insight 3 apply and maybe take action

and for what are the results and how are we assessing those results the next few slides will look at some specific components of the indicators on the dashboard and demonstrate how we use this model look interpret apply and

assess to increase the utilization of the frontline staff in their everyday work this is one of the dashboard components that you saw on the dashboard called buffer time the buffer time is the amount of time left till the patient

scheduled appointment time so for example the patient's appointment time is at 12:00 you can see the check-in time generally what we have found that it takes about 60 minutes from the time the patient checks in to get them into

the procedural room so based on that we have the appointment time at 12 12 o'clock the patient checked in at 10 11 and we have a buffer time you have 21 more minutes to go until there a scheduled appointment

time so let's use the look interpret apply and assess model to help better understand how this dish board indicator works so look as you can see we have multiple patients that have checked in interpret we have three patients

highlighted in red that indicates their past their appointment time and then we have four patients in green indicating time left till scheduled appointment time so what action can we take on this well first I'd look at the red patients

since they're late and I would determine next steps there's an ir case in room two that's nine minutes late and then we have an MRI our nurse that is also nine minutes late and it looks like we have a CT case that has nineteen minutes late

oftentimes I know this just because it's our area but if I was to look at this in our nurses too we would confirm that the CT three case really needed a nurse and generally we don't do procedures in our CT room three as far as the green

patients are concerned we would look at the we'd look at both these two twenty one minute buffer times and say and confirm that the pre-work is on track that we're ready to go and we're going to be able to get those patients in as

far as these two patients you can see they checked in way early then there's 60-minute time and at this point I wouldn't do anything else for that and then as far as assessing generally that's done sort of like later in the

day to discuss in the huddle future actions that needed to be taken maybe to prevent this okay let's try another component of it of our dashboard this here is our procedural patient workup turnaround time so here the first box is

the time in which it takes the RN to do her workup so that might be checking the patient in verifying labs vital signs placing an IV etc and then this middle box is the total workup time which includes the fizz

since time as well so a si and Malley mallampati assessment consent that kind of thing and then the third box is the total time the patient was in the pre room so let's apply our model again so as we can look the RN pre workup is

taking 22 minutes on average the pre procedural workup time total is taking 39 and the total patient time 65 so what can we gather from that as I mentioned earlier we give about us it's about 50 minutes generally when we've done a lot

of audits but we give a 60 minute window so that's why we asked our patients to come in 60 minutes before their before their actual scheduled appointment time so what can we interpret from this so as I'm looking the RN process time is

within 30 minutes so we're good there the total workup time was is in within the 50 minute expectation and we still have our 10 minute buffer remember however the total time in pre exceeds the 60 minute expectation so what action

might we take as a frontline either charge nurse or the any of the nurses say what should we do next so here what I might do is talk to the charge tech who sort of does all the orchestrating of the rooms and say so what's the

possible bottleneck because we've got our patients ready to go within 39 minutes to gain on time start but however it looks like we're stuck I will tell you that there is some of those variations like we had a stroke come in

or a trauma that actually bumps cases we get that piece but why are the rooms running what can we do can we maybe make a person that was scheduled going to room to go into our overflow room in five if say a power authorities like are

less acuity room so those are type of things that we can talk about in real time to get patients moving and so we don't continue to have late start delay so we'll move on to the next one

symptoms we've talked about the location so what are the options now I've kind of scared everybody enough said okay fine if my periods are last in more than

seven days if I have pain with my periods if I have clawed if I have painful sexual intercourse back pain hydronephrosis and sciatica all kinds of these little things then maybe I could be having fibrous what do I do about it

and there are several options obviously I'm here to talk about embolization but because everybody in this room is talking about informed consent every day we have to be able to talk to our patients about what are the options and

I always try to start off with the simplest of options doing something or doing nothing remember this is not a cancer this is a benign disease and it's important that we explain to our patients that they also have the option

of doing nothing although doing nothing has some consequences right every action has a consequence and the consequence of doing nothing includes continuing to have your disease continuing to be sick and abnormal and if you chose to do

something let's say a surgical option then obviously you can have hysterectomy or myomectomy now Maya met to me is just where you're cutting out the fibroid hysterectomy is taking the whole uterus out and then there's a whole series of

other things whether you're having it laparoscopically or transvaginal Eeyore I'm here to talk about uterine artery embolization we offer all of these options to our patients though because it's important that we at least know

that there are other options to be done

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

in providing the analgesic component of procedural sedation they activate opioid receptors in the brain and spinal cord to inhibit transmission of painful impulses fentanyl is the main drug that

we use the onset of action is seen in one to three minutes and the peak effect is seen in five to fifteen the half-life is two to four hours and we typically give a dose of 50 mics to start again it's metabolized by that cyp3a4 what's

especially I think important to note is that it gets metabolized to inactive metabolites so I had a situation when I was a newer nurse I was working in the ICU I had an elderly patient it was my third night with her and she was

admitted for acute kidney injury related to her urosepsis so she really wasn't making a lot of urine and she lives in an incredible amount of pain she has been screaming for two nights and I finally said enough I went to the

resident so we have to give her something so she said let's give her some morphine you want to give her one milligram she's elderly can we at least start with 0.5 and see how she does with that she said that's fine I gave her the

point for five of morphine and she went to sleep maybe thirty minutes later and she looked really comfortable now we didn't we don't or at that time we didn't use capnography for non intubated patience in my ICU I was in but she did

have a pulse oximeter on and all the other monitoring I didn't really disturb her throughout the night I knew she hadn't slept in two days so I would go in and check on her and turn her and see how she was doing and she seemed really

asleep but comfortable I go and do my bedside handover with the day nurse in the morning we go to wake her up and she's not waking up and we do a really good sternal rub and all your nail bed pressure and all those tricks

and nothing's working and she's she's out so we called in the attending in the resident and pees and they ended up doing an arterial blood bath and her paco2 was 75 yes so they did give her narcan and thankfully it worked and she

didn't require intubation the nurse practitioner pulled me over afterwards when things had settled down she said you know I want to talk to you about what happened why did you decide to give her morphine and start a fentanyl and I

said well you know morphine of aura fentanyl rather is a hundred times more potent than morphine and I thought I was doing the right thing because she's an elderly patient I was worried about her cuz she's frail but then she explained

to me that morphine gets metabolized to several different metabolites and one of them is actually 2 to 3 times more potent than the original morphine that you're giving in the IV and because she was in acute renal failure she wasn't

excreting the drug so she had this two to three times more potent drug just circulating around her system all night which led to her respiratory depression and her hypercarbia with fentanyl you have metabolism to inactive metabolites

so it's considered to be more safe for patients who are in renal failure that was a real big aha moment for me because there's a lot that you have to know when you're a nurse especially if you're working in a critical care area and you

hope that you're the providers you're working with are thinking of these things but they're also very stressed so it's all of our responsibilities to know the way that these drugs work and I think it's great in IR because we we

don't give it a lot of medications we give a fair amount but they're pretty much the same medications over and over so we do have an opportunity to really take a better deep dive and really the mechanism of action and their

pharmacokinetic properties considerations you do want to consider renal e impaired patients because it can alter the kinetics meaning that there's decrease protein binding as I said for versed but there is they are slightly

less protein bound than versed and there is a black box warning for cyp3a4 inhibitors specifically for fentanyl just something to keep in mind when you're giving it though I think this is really more I'm talking about patients

that are going home with a fentanyl patch you want to make sure they're not taking inhibitors at home kind of

so reviewing the evidence in relation to respiratory depression and airway

compromise respiratory depressions been identified in ninety and ninety two claims of which seventy seven percent have resulted in severe brain damage or death eighty-eight percent of respiratory

depression events occur within 24 hours of a surgery or sedation related event and 97 percent of these were judged to have been preventable with better monitoring so where does capnography fit in with all of this with with your areas

well if you're starting capnography monitoring in your procedure and carrying that over into the post-operative or the post sedation care unit or in your own recovery units where you're recovering them before you send

these patients to the floor that could be part of a bigger picture they can continue on the capnograph even monitoring onto the floor and be monitored with that so that they are monitored throughout the entire time so

by starting capnography you may be actually implementing a monitoring strategy that hopefully could be carried through for that patient for the next 24-48 hours if they're receiving pain medications and such so when we look at

some of the factors for respiratory compromise we have patient factors right intrinsically they may have diagnosis that we do not know of like obstructive sleep apnea there hasn't been diagnosed polypharmacy some of the treatment

factors things medications that we give illnesses that they're coming in with or lying in bed developing atelectasis maybe have pneumonia they bring in their own illnesses and then the area of care factors right weather monitoring is

continuous or episodic in nature and certainly the interventions and you take all of these things together in this Venn diagram sometimes that can create the perfect storm for creating an adverse event related to either opioids

or sedative use and how do we monitor for that how do we figure out which patients we need to monitor there's so many complex factors we really need to anticipate the consequences right and monitor appropriately so moving on to

etiology and I keep the slide in here and I know it looks very basic oxygenation and ventilation oxygenation process of getting oxygen into the body onto the red blood cells and transported to these cells for cellular metabolism

and Krebs cycle whereas ventilation is removing carbon dioxide from the body these are two separate physiologic processes and sometimes these terms are used appropriately interchangeably they are

related to one another but they are separate processes we can oxygenate patients with ECMO with passive oxygen APNIC oxygenation High Flow oxygen but can we eliminate carbon dioxide without ventilation and the answer is no we need

to ventilate to get the co2 out and the co2 is a very important regulator of pH so how do we monitor ventilation and

anatomy of ayres in healthcare so this

is according to ashram which is the American Society for healthcare risk managers this is my professional organization and what they say is the anatomy of patient safety errors is that we have a blunt end of the system and

then we have a sharp end of the system and the blunt end of the system you'll find your organizational factors like your culture your policies your procedures and regulations and you're gonna pass through those things that we

know all too well which is our environmental factors that have to do with our equipment our staffing our resources and our constraints and lastly we come to the sharp end of the system which are you and I at the

bedside alright so and this is where our human factors come into play if we are we have a lot of tasks overload under load communications not quite where it needs to be we're fatigued or stressed we're

thinking about other things our blue wall that we like suddenly turn beige so clinical competency comes into place here also the skill set of the person so your managers out there it's very important to know the skill set of your

people and of course our Kunik communication skills so patient safety used to focus on the sharp end you may remember a time when a patient safety event happened and you got called into a room with a group of people and the

event was on powerpoint slides you go through the event and then you're asked a lot of questions from this lineup of people and you it feels very much like the Inquisition well what we found was that wasn't very helpful at getting to

the root of the cause because oftentimes it's not the person it's what is happening in the organization that leads to that event the workarounds that we have to do because we know that a policy and procedure really needs to be tweaked

it's not representing the practice that we do any longer so we focus now risk management focuses on the system what was the system ere and how can we fix that and we do that now by interviewing the people who are involved with the

event and one of my favorite questions is to ask if you had to do it all over again what would you do differently that's my favorite question because it really lets me know what needs to be changed from an organization standpoint

and then that's when the leaders come in so then we get together with the eaters and sit down with the leaders and effects some real change for our staff at the bedside all right education

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

interesting to grapefruit if a few YP three a-four inhibitor so I always remembered from nursing school they said

don't give grapefruit but I never really knew why but that's why it's just inhibiting the enzyme that's required for metabolism flumazenil is the reversal agent for benzodiazepines your initial dose is going to be 0.2

milligrams over 15 seconds what's important to note about flumazenil other than the seizures that I mentioned before is that the half-life is shorter for flumazenil than it is for versed so you can see a recitation effect which is

why you really need to monitor them for a good period of time after you're giving it and monitor to make sure they don't become reefa dated we're all familiar with narcan it's the reversal agents for opioid medications the

initial dose is 0.4 milligrams given over 30 seconds and you can repeat every one to three minutes to a maximum of ten milligrams other medications I think are useful to mention because you do see them and I are usually given by an

anesthesiologist propofol is a great drug onset of action is less than one minute but it's a potent drug so you can see significant hypotension and respiratory depression for us in New York it's not permitted for use by non

anesthesiologists Dex Mehta Tommy Dean is another interesting drug that's sort of getting into the kind of talk in the IR world so in the 2018 guidelines that I mentioned before they address sex medicine

and they said that it could be an alternative for versed in particular cases it's a highly selective centrally acting alpha-2 agonist with eggsy oolitic sedative and some analgesic effects

you usually administer it as a bolus over 10 minutes and then you start a continuous infusion however some of the very potent bradycardia that you can see can be mitigated by eliminating the bolus infusion or the bolus

administration rather and significant considerations with this are hypotension and bradycardia does anyone use pres iudex in their ir suite oh you do okay you guys give it cool we'll talk our our anesthesiologists are

a little territorial with it however the research does show that it does have a better safety profile in certain patients so it you know yeah so that's my experience with it but our particular anesthesiologist that oversees our

sedation committee and all of our sedation practices is concerned about us using in an ir because not all the practitioners have experience administering it there's not a reversal so if the patient became bradycardic you

would have to treat their bradycardia with fluids or atropine or other medications for your particular institution yeah right it yes yes always look at your state guidelines yes so the a what the a sa says about the

is my cap nog Rafi reading actually I want to back up a little bit here do I want to back up no I don't I don't want to back up so um let's look at the first

question why is my cap nog Rafi reading abnormal so let's first talk about physiology so a question I get a lot of times is sue the patient comes down for a procedure to the floor I put a sample line set on

them I plug them into the monitor and I'm getting a value of 28 29 30 why are my values abnormal anyone ever see this is anyone still awake okay so there's a few reasons the patients that we are dealing with generally aren't

healthy right I mean sometimes I go to work and I get chest pain I'm like can I just be in an ambulatory gallbladder room today because the patients that are coming from down to IR are sick what their physiology is sick too so we have

Krebs cycle we take oxygen in right it circulates to ourselves it participates in aerobic metabolism we get the byproducts of heat and energy and we get carbon dioxide as a by-product carbon dioxide really diffuse about diffuses

into our blood travels to the lungs and gets exhaled where we measure it so let's talk metabolism really quickly so if someone has a fever if their metabolism is ramped up you think they're gonna be producing more carbon

dioxide yes let's say they're a little hypothermic maybe they're gonna be producing a little bit less you see it for sure in the car patients who are cardiac arrest that are cool to status post cardiac

arrest right those values go way down normal physiology normal physiologic response somebody comes down and they're mildly hypoxic they've got pneumonia or some sort of VQ mismatch and they're hyperventilating to UM debeso

compensate for their hypoxia do you think there's co2 values gonna be a little lower at baseline yeah so these are the patients that you're seeing right so we have reasons that patients could be hyper cap neck like metabolism

right somebody who's in pain someone who's developing a fever early stages of sepsis they may actually have a little bit of a higher value somebody who's sedated or hypoventilating may have a higher value and when we talk about

perfusion is the blood moving round and round is that circulating co2 coming back to the core do we have increased cardiac output with continuous constant ventilation and certainly we can we're gonna look at equipment issues next and

the same goes true more probably in your cases of the hypocapnia patient so someone who is not fully exhaling someone who's in bronchospasm or a COPD or you're not getting that nice square waveform you're only getting some of the

mixed gas ventilation that they're exhaling rights and the conducting airway is mixing with the alveolar gases someone's a little hypothermic someone who's been NPO for 24 hours right it's the opposite of carb-loading right so

you kind of throw them into a little bit of like acidosis you know they're kind of not burning carbs for fuel are they gonna be producing as much carbon dioxide not so much right so when you're coming so when

patients come down to you and you put them on the monitor consider these things so ventilation perfusion gradients so we have what we call our VQ matches and our body is designed beautifully right so when everything is

working great it works great so the way we ventilate all of our lungs owns is very closely matched to the perfusion of all of our lungs ohms so by me standing up here I'd like to think I'm pretty healthy if you did a blood gas and you

put me on one of those filter line sets right now you would hopefully see a gradient that's very small the normal gradient between a PA co2 on a blood gas so the level of carbon dioxide on a blood gas in the arterial blood and what

you see when I fully exhale into the monitor should be between two and five millimeters so these are your patients come down healthy physiology you put them on and you get a value of like 32 then you

could assume that if they were healthy two to five millimeters okay their blood gas would probably like 35 for POC to everyone follow now does any of our patients read the physiology tech books textbooks no they typically don't so

when you have patients come down they may have shunt right so they may have we have our little airway here a and B you're out like picture them as lungs and lung a is blocked so we have no ventilation going to lung a but blood is

still chugging through right so blood is still going through the pulmonary circuit so we're gonna have Patapsco a dia depending on the size of the shunt is this the end of the world are we gonna cancel the case no but just being

aware of the patient's physiology would explain to you why I put this patient on this and I'm getting a value of 30 you follow and it's not the end of the world you document 30 and you monitor for trends as you're going along with your

sedation same thing goes through with dead space dead spaces were ventilating but we have an area of the lung that is not being perfused pulmonary emboli other circulations some medications hypovolemia shocky patients same thing

the VQ mismatch not the end of the world it's part of the patient's physiology maybe part of the reason why they're down there just being aware of these things though so the technology works right our equipment works if just amazed

it's picking up something that we don't connect all the dots on physiologically that sometimes confuses us a little bit so I hope that clears up part of it so when we're monitoring capnography certainly ventilation is what we think

of first and it's important co2 being expired by the lungs that's what we're looking for but if we back up and look at the physiology of carbon dioxide production in the body we are also inferring that

it's being metabolized and being created from Krebs cycle and aerobic metabolism and that we have perfusion occurring okay I'm sure if some of us have seen in our you know nursing careers patients who are kind of peri-arrest and

the capnography kind of drops off it's like a poor man's swan you're watching cardiac output drop in real time because carbon carbon dioxide is not being delivered to the lungs so when we're looking at our patients when

they first come down we first want to establish a baseline value we want to put on a monitor have a patient take some nice deep breaths full ventilations not just one but a few you want to you know have them take a few and look at

their other vital signs their mental baseline status and we're gonna look for trends in their carbon dioxide value so if someone starts off at twenty nine I don't care that they're not 35 to 45 which is textbook normal this person may

not have the stimulus to breathe if I let too much co2 accumulate so we're really looking for the trends okay now somebody will say well how much of you know how much should we look for 10 to 20 percent change from your baseline is

somewhere where you want to start paying attention to what's going on okay maybe like titrating your sedation or just being a little bit more cautious with how much more sedation but again it's more important to look at the trend

value behavior of your carbon dioxide than it is the absolute numbers themselves so first you having a problem let's consider the patient's physiology

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

riesen comes to us and he talks about

some theories on why we make mistakes so and we're gonna cover these and then we're gonna cover the Swiss cheese model which many of you may be aware of so sorry slips tend to hurt current situations that are so routine that

they've become rote so an example of a slip could be selecting the wrong drug from a drop-down alright so again slips and lapses occur when the correct plan is made but executed incorrectly so we have that drop down of drugs but we just

select the wrong one that's a slip a lapse is generally not visible because it's reflective of a memory failure so for instance we may have a patient who forgets to take their medications or we may have a prescriber that forgets to

take a drug off of a med rec so those are examples of slips or lapses mistakes or judgment failures they're more subtle and they're complex than slips and these can go undetected for a period of time and they're often left to

a difference of opinion well I don't do it the same way that Mary does it who doesn't do it the same way that sue does it so those are mistakes and their knowledge base we know the right thing to do but because we have outside things

that are occurring situations that are occurring we may have to do some workarounds and those workarounds aren't always safe or we're gonna get in and this is part of the anatomy we're gonna get into the anatomy a little bit later

and often mistakes are rule-based so we know the rules we know what we're supposed to do but for factors that are out of our control we bypass those and that's when mistakes can happen active failure failures are highly visible

errors and we usually see these because they have immediate consequences and then the latent failures their processes that are under the radar they come from not following policies and there may be a good reason why we're not following

policies but oftentimes we hear that we've always done it that way and that means they're rooted in culture so that's where the justa culture comes into play all right Swiss cheese model so this is this is probably a graphic

that's very familiar to a lot of people but it does really it's it's at the basis of a patient safety air so organizations have defenses those are the slices of cheese now those defenses although we'd like them to be solid

they're oftentimes not they're filled with holes because of human factors the human condition those active and latent failures the slips lapses and mistakes that happen to all of us it's a part of us so often some of those defenses get

penetrated but then there's another defense that stops let's take for example identifying a patient so a patient comes in and maybe they're not english-speaking they may be

spanish-speaking and so we call their name and they answer the answer yes because it's close enough right it's close just close enough and they come up we don't check anything we don't check don't verify their name and their date

of birth we pass them on to our prep recovery room and then we're getting them ready because we have confidence that Jane at our front desk she doesn't make an error she always identifies the right patient so we have a high level of

confidence in Jane it's not a bad thing that's an OK Fay but here again we're not doing what we know is in our policy so it's rule-based and that we know is the right thing to do so it's knowledge base so it becomes a

mistake that we're not checking our patients identity and date of birth and that patient gets back to let's say the interventional room and boom we stop because now we're doing a timeout and we identify that we have the wrong patient

for our procedure and it stops but sometimes these heirs line up the holes line up and it's just one of those days and we end up with a patient safety event at the end so now we come to the

this is nursing case volume per hour so

staffing is a consistent challenge as I mentioned before having dashboards helps to make real-time decisions to help allocate nursing resources during high-volume times so this dashboard indicator

identifies the distribution of nursing workload over the course of the day I love this one for me especially as a nurse manager especially since me knows Tommy says they they feel like oh my god it's so busy it's so busy it's so

chaotic and you're trying to help them you know well of course I understand why it is now so I actually have data to understand their story and help them to see the data and why they feel it's chaotic so again with the help of color

coding the ability to look and interpret the data is simple so here since I've taken you through a few I thought I'd throw it out to everybody and see what if you wanted to kind of take a stab at using our model so if showing or if

anyone wants to raise their hand so what are you seeing here in this dashboard a lot of what you owe to our cases yeah anything else are you seeing yes correct there's nothing happen at 8 o'clock anything else right yep

sort of a lull here correct so what might you interpret from that in other words so what would you kind of see your say about this I'm sorry can be allowed a long time oh yes yep exactly right and so so then

what action might we take here to help sort of get rid of sort of the high volume times yes exactly so here's where you would shift the staffing to help cover the high volume areas and so I'll just take you through what how since

it's what we do at D H I'll take you through so exactly right I think someone pointed out that you have nurse cases except for say at 8 and at 6 and 6 generally we're just doing recovery at that point we don't need any more cases

going through interpret wise so we have this Pio nurse as you can see in the magenta and I'll tell you a little that's our MRI nurse to specific for MRI doing Pio sedates as Chris mentioned we have an MRI nurse there and we also do

cover pacemakers as well and those that's her caseload as far as non sedation we actually just have we sort of as people aren't busier in between rooms is when they might go you know give lasix for a year gram or you know

port access or what have you so what I'm looking as interpret I have a Pio nurse available seven several times a day so only in the magenta is she busy or he and then the best times may be for IR addons is between like say 11 and 12

here I would potentially my action would be to say hey this pio nerves could actually come and help get cases started and get them on time and then also come and maybe relieve lunches that's another I'm sure probably an issue for everyone

is like you're down a couple staff during that time but we're still running our rooms great that was a great job very good okay so a couple more to just kind of quickly show the pending patient workup documentation so this gives the

ability of the frontline RN to have instant visuals of the electronic medical records documentation that needs workup and phone calls that are needed to be completed for future patients so again let's use our model

so look there are a lot of workup phone calls pending and remember this is real time so in this case if you were looking this is just a snapshot but say today is March 4th okay going around so the first thing I'm saying yep there's a lot of

cases I've got 14 here and it shows a couple of days worth obviously you can see how the numbers add up I'm looking at the high number of same-day pending work for procedures so you can see here three four five six work ups and I have

nine phone calls to be made and I'm looking at the MRI work up calls and right now there are a couple days out so I'm opening less concerned about that so how would I apply and what action would I take well first I would clarify that

these same day workup and phone calls are actually pending sometimes they might have been done or someone missed hitting the icon on our computer and then I would prioritize completion of pending work so I might say to a couple

nurses that are in between rooms or whatever can you make a couple of phone calls we've missed this and we need to get contact with the patient and then of course I would obviously prioritize the I our work ups before the MRI ones

because there are a couple days out okay

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

culture concept so the single greatest impediment to err prevention in the

medical industry is that we punish people for making a mistake we should learn right we should really learn so what comes to mind when you think about it the term just culture right she's being able to

report something and not having having punitive actions from that Lane free fair open and honest trustworthy supportive nice place to work yes so two nurses select the wrong medication from a dispensing system

one dose reaches the patient causing him to go into cardiac arrest and the other is caught at the bedside before causing harm do we treat these nurses in the same way no we should but oftentimes we don't right

right right so an active failure versus more the latent failure right so upon further investigation it showed that the two vials that these nurses pulled were very similar the vials was very similar to something that wears a different

medication so we needed some separation from pharmacy so so a little systems intervention right in our Omni cells so and maybe you know maybe there's some human factors that were involved there too that you know one nurse caught it

and the other one didn't but rather than punishing we need to work on consoling and supporting and look at the system and find what's happening what's going on what's the root cause a nurse loses custody of yet an unlabeled specimen but

chooses not to report the incident at a fear of discipline do we fur grit forgive the breach given the nurses fear no no so we really can't but we shouldn't come down on her like a hammer you know or on them doesn't have

to be heard on them because this can actually be a sentinel event if if you have to go back and get another sample that's a set a little bit so that's a Joint Commission never event so that that's not that's not a good thing plus

it's an extreme inconvenience to the patient and also we're opening that patient up to further harm because we have to get another sample so you have to ask why did the nurse behave this way why did she choose not to report it

honest honest disclosure without fear of retribution that's an important characteristic of the just culture hmm yes it does doesn't it that's an excellent point thank you very much for

sharing that excellent point certainly she said that you also have to look at leadership because a lot of times leadership has favoritism so you've got to work on the favoritism so it has to be fair and that's also part

of the just culture and that's a very good point as a learning experience and we're gonna cover some of that too so we have a radiology team that defends skipping the timeout on the basis that no adverse event occurred

so do we condone this no no no so we we don't condone it and it is it is a Joint Commission requirement but and although this incident didn't end in an adverse event we could certainly see where it might so again we need to engage our

leadership we need to engage people at the bedside including our physicians as to you know why we blew right through the timeout so a fair and just culture is is a culture that refers to values supportive model with shared

accountability um it's also an integrated pattern of individual and organizational behaviors based upon shared beliefs and values that continuously cease to minimize patient harm that may result from the processes

of care delivery so culture is the outcome of how our organization responds it's the outcome so if we have a just culture we will have people who will report those events those near misses and will work and not hide them and do

what's right that's why we need it because if we don't have it only two to three percent of errors would be reported most hospitals would be unaware of what errors they had health care workers would report only what they

could not hide and airs as viewed by hospital workers and the media are indicators of carelessness which is not true in fact it's farthest from the fact

so we have some human factors that reduce situational awareness situational

awareness is our mental model of the world around us so I'm sure you're all very familiar with your interventional radiology rooms your CT rooms your MRI rooms and it may take you a little while because of

different human factors that are going on many of which I have listed here to realize that perhaps over a weekend weekend a blue wall got painted beige so some of these factors are insufficient communication fatigue and stress task

overload tasks under load group mindset press on regardless mentality have you ever had that from some of your Doc's in the IR room it's like you've got three cases to go and you know it's getting time that you know your staff have been

there for a while and they're let's push on we gotta get these cases done we're really opening ourselves up for air so again here's that action versus non action so we could really have some of that non action and maybe reassess those

patients and see if we can't have them wait till the next day it's a little bit safer to do those procedures and degraded operating conditions so I have a little test ready all right so this is actually a commercial that came out of

the UK and the UK was using this to heighten awareness for their drivers for motorcyclists being on the road but what it goes through is that we have a kind of a clue a clue ask type of setting where we have our trench coat detective

and we have a lineup of suspects for the murder of Lord Smythe who unfortunately is there on the floor and he's going to go through his lineup and ask them questions and he's gonna name the question but this is about the

world around you I want you to pay attention not only to what's going on but there are things that are happening in that environment that are changing and I'd like you to see how many you notice while you're watching our

detective go through his inquiry clearly somebody in this room murdered Lord Smythe who at precisely 3:30 4:00 this afternoon was brutally bludgeoned to death with a blunt instrument I want each of you to tell me your whereabouts

and precisely the time that this dastardly deed took place I was polishing the brass in the master bedroom I was buttering his Lordships scones below stairs so what I was planting my petunias in the potting shed

cussed of all a rest lady Smythe but how did you know madam has any horticulturist will tell you one does not plant petunias until May is out take her away it's just a matter of observation the

real question is how observant were you all right so how many changes did you happen to see I was gonna say would it surprise you I hit stop it in time um would it surprise you that there were 21 changes during this little yeah yeah

right yeah so how many caught late about five yeah but yeah right right so that's why communication is important and it is often one of those human factors that we don't pay attention to how key communication is in

preventing patient safety errors so let's take a look at what we what we did or didn't see clearly somebody in this room murdered Lord Smythe who at precisely 3:30 4:00 this afternoon was brutally bludgeoned to death with a

blunt instrument I want each of you to tell me your whereabouts at precisely the time that this dastardly place I was polishing the brass I was buttering his Lordships scones below stairs or something but I was fucking my petunias

in the potting shed touch the ball arrest lady Smythe right right originally yes is to increase that situational awareness where you've got motorcycles coming in from sides or in front or behind you or coming you know

all different directions that's what that was originally done for but there are a lot of those situational videos that are out there the probably the most famous is the one with the gorillas and you've got like I don't know ten people

that have the basketball and they're in different shirts and the task is you're supposed to watch the number of times that the white shirts versus the black shirts catch the ball right and in the middle of it comes this dancing gorilla

and most of the people miss the dancing gorilla because you're so focused on watching the ball well the same thing here you're so busy watching our trench coat detective interview to get to the end who did it

cuz you know they're gonna tell you I told you who's that they're gonna let you know who did it that you've miss all those things that are occurring around you so the reason why I did this is because it does involve a lot of

situational awareness and and situational awareness is around us every day and when we're taking care of our patients so it's those little things that we see when we see those changes in the monitor of our patient those little

things that happen in the room that you know maybe they're doing some reconstruction in your IR lab and your your MRI or something and and you've got to do a little workaround well that's not in your and we're gonna cover this a

little bit later with James riesen but that's not what you're used to and so your situational awareness changes and if you don't realize what's going on you may miss something and that something may be something very significant for

your patient and that's where those human factors come in where we have task overload under load communication factors that press on regardless how dangerous that can actually be so James

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