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Contraindicated Sites for IV Insertion | Preventing Extravasation: The Nursing Role in Power Injection and Access Selection
Contraindicated Sites for IV Insertion | Preventing Extravasation: The Nursing Role in Power Injection and Access Selection
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Contrast Media Administration - Competency | Preventing Extravasation: The Nursing Role in Power Injection and Access Selection
Contrast Media Administration - Competency | Preventing Extravasation: The Nursing Role in Power Injection and Access Selection
accesschaptercontrastextravasationfull videoinjectintravenousperipheralradiologistradiologistsregisteredtechnologistsvenous
Importance of Fast IV Injection Rates - CT Scan Rates | Preventing Extravasation: The Nursing Role in Power Injection and Access Selection
Importance of Fast IV Injection Rates - CT Scan Rates | Preventing Extravasation: The Nursing Role in Power Injection and Access Selection
chaptercontrastfastfull videoimagesinjectionperformportalqualityradiologistratesstructuresstudiesutilizingversus
Geniculate Nerve Ablation and Thermal RFA | Nerve Blocks, Neurolysis, and Rizotomies
Geniculate Nerve Ablation and Thermal RFA | Nerve Blocks, Neurolysis, and Rizotomies
2018ablationarinAVIRbupivacainechapterfull videoinferiorlateralmedialsuperior
Extravasation vs Infiltration - What is a Vesicant | Preventing Extravasation: The Nursing Role in Power Injection and Access Selection
Extravasation vs Infiltration - What is a Vesicant | Preventing Extravasation: The Nursing Role in Power Injection and Access Selection
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Risk Factors - Skill of the HCP | Preventing Extravasation: The Nursing Role in Power Injection and Access Selection
Risk Factors - Skill of the HCP | Preventing Extravasation: The Nursing Role in Power Injection and Access Selection
administrationassessingbloodchaptercontrastfull videoinjectinjectioninsertionpalpableperipheralsite
Risk Factors and Comorbidities for Contrast Extravasation | Preventing Extravasation: The Nursing Role in Power Injection and Access Selection
Risk Factors and Comorbidities for Contrast Extravasation | Preventing Extravasation: The Nursing Role in Power Injection and Access Selection
administrationagentsaxillarycancerchapterchemocliniciancomorbiditiescontrastdiagnosticextravasationfactorsfull videoinjectioniodinatedmediamultiplepatientpatientspediatricradiologicrisksloanvascularveinsvolumes
Needle Guidance | Pushing the Envelope: Needle Guidance and 3D Applications in MSK Intervention
Needle Guidance | Pushing the Envelope: Needle Guidance and 3D Applications in MSK Intervention
2018ablationalignarinAVIRchapterfull videoguidancehydrodissectionnarrowneedleoverlayplacementstraight
Q&A | Joanna Po Lecture Series: Totally Rad Introductory Competencies
Q&A | Joanna Po Lecture Series: Totally Rad Introductory Competencies
allergicchaptercompetencyfull videonursesradiologyweeks
Incidence and Causes of Contrast Extravasation | Preventing Extravasation: The Nursing Role in Power Injection and Access Selection
Incidence and Causes of Contrast Extravasation | Preventing Extravasation: The Nursing Role in Power Injection and Access Selection
causedchaptercontrastdislodgedextravasationfull videomalpositionedmediarupturesitevenous
Neuropathic Pain in R Ribs | Thermal RFA | Nerve Blocks, Neurolysis, and Rizotomies
Neuropathic Pain in R Ribs | Thermal RFA | Nerve Blocks, Neurolysis, and Rizotomies
2018arinAVIRchapterfull videointercostalpainpleuralsagittalskinthermalultrasound
The Essence of the Radiology Nurse | Joanna Po Lecture Series: Totally Rad Introductory Competencies
The Essence of the Radiology Nurse | Joanna Po Lecture Series: Totally Rad Introductory Competencies
chaptercodecompetencyessencefloorfull videomedsmocknurseongoingphysiciansradioactiveradiologyrespondingsurgthrombolysis
The Process of Creating a Competency Checklist | Joanna Po Lecture Series: Totally Rad Introductory Competencies
The Process of Creating a Competency Checklist | Joanna Po Lecture Series: Totally Rad Introductory Competencies
chapterchecklistcompetenciescompetencycoredemonstratesfull videolearningnursenursespracticeradiologyskillsspecifictechnicalwright
Documentation of Competency Assessment - An Example Checklist for an IR Nurse | Joanna Po Lecture Series: Totally Rad Introductory Competencies
Documentation of Competency Assessment - An Example Checklist for an IR Nurse | Joanna Po Lecture Series: Totally Rad Introductory Competencies
carechaptercompetenciescompetencyconsistentlycoredemonstratesdocumentsexposurefull videohopkinshospitallearningminimizeneuronursesnursingpatientpositioningveinvenousvital
Ablation Devices in Neurolysis and Rhizotomies | Nerve Blocks, Neurolysis, and Rizotomies
Ablation Devices in Neurolysis and Rhizotomies | Nerve Blocks, Neurolysis, and Rizotomies
2018ablationarinAVIRbasicallychapterconductioncryoablationdorsalfull videonervepulsedthermal
Key Points | Joanna Po Lecture Series: Totally Rad Introductory Competencies
Key Points | Joanna Po Lecture Series: Totally Rad Introductory Competencies
chapterchecklistcommunicationcompetenciesdomainsfull videoskills
Meaningful Competency | Joanna Po Lecture Series: Totally Rad Introductory Competencies
Meaningful Competency | Joanna Po Lecture Series: Totally Rad Introductory Competencies
chapterchecklistcompetenciesdeemedfull videolistorientationskillsstay
Routine Use Of Ultrasound To Avoid Complications During Placement Of Tunneled Dialysis Catheters: Analysis Of 2805 Cases
Routine Use Of Ultrasound To Avoid Complications During Placement Of Tunneled Dialysis Catheters: Analysis Of 2805 Cases
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know the difficulty with placement pedicle screws and despite the fact we all think we're we're good at it and

we're experienced at it we also know that screws are occasionally misplaced and this technology should allow the safer placement of screws more accurate placement screws for patient safety but also it should increase the speed the screws

are actually placed for operative workflow.

Now, we have high-risk sites, which is the back of the hand, the wrist, the foot, and the ankle.

And we also have contra-indicated sites, which are the extremities that have evidence of phlebitis or infection. We have extremities with AV fistula or AV graft, extremities with lymphedema, and those extremities

that have had axillary lymph node dissection. On the screen is an algorithm that is part of our intravenous line placement and medication administration in patients who have had axillary surgery. There are two very important things to determine

before you proceed. First would be the type of axillary surgery. Was it a sentinel node biopsy? Or was it an axillary node dissection? Sentinel node biopsy is defined as the, is defined by the removal of one to four lymph nodes

on any given side. If a patient has had a sentinel node biopsy, that side can still be used for IV access and medication administration, as long as there is no evidence of lymphedema. Axillary node dissection, though,

is the removal of five to 30 lymph nodes on any given side. That side should be avoided unless it is an extreme emergency. There is a discussion between the LIP and the radiology team about risks versus the benefits, and also, we need an LIP order to use,

as well as the absence of lymphedema. When there's a lymphedema, no, we cannot use it.

Who can inject contrast? The laws on who can inject contrast vary from state to state, and in New York State, the registered nurses and radiologists can administer contrast via power-injection through peripheral venous access

as well as central venous access devices. Trained and competent registered technologists are allowed to inject intravenous contrast media through peripheral veins only, and only when a radiologist is present and accessible, in case any complications occur.

As imaging technology continues to evolve, there is an increased requirement for faster injection rates of intravenous contrast media. Therefore, extravasation is a concern for patients undergoing CT studies requiring power injection.

Nursing in diagnostic imaging. Ammeruth and I work

at the Laurance Rockefeller Outpatient Pavilion. It is one of the three outpatient sites in Manhattan alone, of the Memorial Sloan Kettering Cancer Center's department of radiology. On staff, we have 10 registered nurses, 12 CT technologists, 10 MRI technologists,

we have three CT scanners, and two magnets. On any given day, we have a staff of six to seven nurses in the unit, and in 2017 alone, we scanned a total of 11,657 CT patients and 4,313 MRI patients.

Okay, this slide, are radiographic images, of an extravasation in the dorsum of the hand on the left, on your left side,

and on the antecubital fossa on your right. The image on your left shows us a large volume of extravasated contrast media in a small space, in the hand, and the image on the right shows us, a large volume extravasation in a larger space. So when you look at these two images,

which of the two do you think would be at most risk for complications? Yes, perfect, thank you. This is a perfect example of how volume and location impact patient outcomes.

Why are fast injection rates important? It is important because it allows for optimum enhancement of normal and abnormal structures in the body. It adds quality, value, and extent to the images.

At our institution, the maximum injection rate we currently use is 6 ml per second for CT angiographies. And when we are faced with the issue of image quality versus the risk of extravasation, I always remember what our favorite radiologist

always tells us: Maria, image quality is important, but patient safety comes first. There is a reason why we love him. But also, it depends on who you're talking to. Some radiologists would not even think of that. And here are studies that require fast injection rates

that we usually perform at our institution. And of all these studies, it is the liver and the pancreas studies that make up a large percentage of imaging that we perform at our institution. Now these are images of a CT of the chest

with IV contrast utilizing a one ml per second injection on your left, and a 2.5 ml injection on your right. You can see there is better enhancement, the blood vessels are clearer, the structures are clearer. And I have another slide

that will show us the CT of the abdomen with IV contrast utilizing a one ml per second injection versus a 2.5 ml per second injection. What can you see in the images on the right that you cannot see on the left? Blood vessels, yes, thank you.

You can see very clearly on the right, there are the normal structures, and you have the lesion on the liver, and there's something on the kidney that looks like maybe it's mets, or maybe it's just a cyst, hopefully.

And you see the spleen and the stomach, and there you can see, let me try this, right there, yay, okay, that is the main portal vein, and somewhere here is the hepatic artery, arteries. So having said that,

(laughs) I'm almost done. (Maria and audience laughing) Having said that, these images, oh, sorry, okay, these images clearly demonstrate that fast injection rates are essential

to achieve high quality diagnosis. However, as nurses, and as advocates for our patients, we should always remember that patient safety is still our priority.

Before we give the contrast, we perform a pre-procedure verification process, this is essentially the timeout.

How many of you guys perform timeout prior to giving contrast? So not everyone, okay. In MSK, we do a timeout prior to giving contrast. We properly identify patient using two patient identifiers,

the MRN, medical record number of the patient, or the full name of the patient. We also review the protocol and order for the contrast to make sure that we have the correct study. We verify that we have the right contrast, we have the right amount of contrast,

and, of course, the right rate. This is our verification form. Again, we confirm the patient's identity using at least two identifiers, we confirm the radiologic procedure to be performed, and we confirm the contrast type, amount, and rate.

So if the patient comes in for a double study, we do a second verification, like a second timeout. Part of our nursing consideration is also patient education. Of course we have to tell the patient

what type of contrast they are getting, what is the normal side effects, because the feeling of warm feeling, that metallic taste, can be overwhelming for some patients. And also, we have to also educate them regarding the signs of contrast complications.

Like hey, if you feel itchy, if you get short of breath, you let us know right away so we can intervene.

We're doing this in the knee where we do the geniculate nerves. We target the medial and lateral superior geniculate nerves, as well as the inferior medial geniculate nerve.

This is the approach, you can see the probe placed right where the geniculate nerve lives in the lateral position. This is what it looks like when we're placing the probes. We place these sheath needles. We inject some bupivacaine and lidocaine,

and then we form the RFA. This is another patient where we performed the medial and lateral superior geniculate and then the inferior medial geniculate ablation with significant relief of this patient's pain.

What is extravasation,

and how does that differ from an infiltration? These are two words that are often used to describe the accidental leaking of an intravenous solution or medication into the surrounding tissue outside of the vein. The difference between the two,

is the type of solution that is leaked out of the vein into the surrounding tissue. When a non-vesicant solution is inadvertently administered into the surrounding tissue, it is called an infiltration. It is now an extravasation when a vesicant solution is administered into the surrounding tissues inadvertently.

What is a vesicant? A vesicant is an agent that has the ability to cause blistering, ulceration, and tissue necrosis. These are examples of some vesicants. We have chemotherapy and biotherapy agents, such as the vinca alkaloids and the anthracyclines.

We have some antibiotics and medications, such as nafcillin, vancomycin, propofol, sodium bicarb. And then we have parenteral nutrition solutions, we have vasodilators and vasopressors, such as epinephrin, Levophed, dopamine.

And last but not least, we have the radiologic contrast media, which is often referred to as a lesser known vesicants.

I love this picture.

This illustration brings me to my third group of risk factors, which is, the healthcare professional's skills of IV insertion and assessment skills. Before I forget, I am so proud to be part of a group of nurses in my institution who are so good at what they do.

They cannot be here today, but they are so good at what they do. Now, this slide, what this slide means, is that the safe administration of contrast media depends on your skills as a nurse. In terms of your ability to identify the high-risk sites,

to choose the right location, to use the proper IV insertion techniques, and to assess previously placed IVs. Previously inserted IVs assessment should include the following: peripheral IV sites,

oops, sorry, peripheral IV sites that are greater than 24 hours of insertion. That IV site is at a greater risk for extravasation. Is the catheter power-injectable or not? Are there are multiple venipuncture sites

above, right above the site of injection? Are there dressings hiding the injection site, which prevents us from assessing the injection site before, during, and after the injection of contrast media. How many of you here have injected peripheral IV lines with contrast media which does not give us any blood return?

Anyone? We have a policy, not a policy but guidelines, for intravenous contrast administration via power-injection. It states that blood return is preferred but not essential, in the presence of an adequate flush, and a palpable thrill, because if there is a flush,

it flushes very well, and it has a palpable thrill, it is a good IV. And another thing I would like to mention. If you're assessing an IV site that does not have any blood return, it would be a good thing for you to inject that IV also.

Do not give it to your peers to inject and hope nothing happens. (audience laughs)

Now, let's go to the risk factors of contrast extravasation. I've grouped them into three. First are the patient factors. In patient factors we have age,

the elderly and pediatric patients, because of their small, fragile veins, and their reduced ability to report symptoms. Then we have patients with altered mental status, because of their inability to communicate effectively. And, another is a history of extravasation.

This information is usually volunteered by the patient themselves, and believe me, they know exactly when it happened, which institution it happened, and even if the nurse did everything right and it was not her fault,

she is going to be the person responsible for the extravasation. Therefore, as clinicians, we should make every effort to try other sites first before that site of previous extravasation. And under patient factors,

we have comorbidities that further increase their risk. And first we have patients with vascular diseases such as Raynaud's, patients with diabetes, because of poor vascular circulation, and third, is very relevant to our institution, is cancer.

Memorial Sloan Kettering Cancer Center is a tertiary care cancer center. And the patients who come to us for cancer treatment require hospitalization, and surgeries with or without axillary node dissections. They also have to through multiple laboratory tests,

which equals multiple venipunctures. Frequent diagnostic radiology, diagnostic imaging studies, for diagnosing the extent of disease, or to evaluate the effectiveness of treatment. And that also equals multiple venipunctures

plus the injection of a vesicant, which is the radiologic contrast medias. They also go for radiation therapy and chemotherapy. Chemotherapy involves the administration of vesicant, sclerosing, and irritating agents through the patient's veins.

All of these factors result to what our patients love to call their chemo veins. What are chemo veins? Chemo veins are veins that are hard, they are scarred, they are sclerosed, and they move. And in very extreme circumstances,

you've got that vein but there's no blood return, nothing. Now let's go to the next group of risk factors that I love to call the contrast media factors. First is the type of contrast. Almost all contrast media are categorized as vesicants, and that goes for both iodinated contrast media

and the gadolinium-based contrast agents for MRI. We have the methods of administration, which is automated power injection, which allows for large volumes of extravasated contrast media in a short period of time. As opposed to a hand injection or a straight injection,

where the clinician injecting has absolute control over the administration of contrast. Third, larger volumes to be infused, and faster injection rates. These all contribute to increased risk of contrast media extravasation.

Having said that, iodinated contrast agents have a far greater risk of extravasation than that of gadolinium-based contrast agents. In terms of their method of administration which is power injection, the volume, which are larger volumes to be infused,

and the faster injection rates required within the protocol. So all of these factors are all associated to increased instances of contrast media extravasation.

In a perfect world,

this is how the veins of all our patients should look like when they come to us. The area of the triangle there, is the most commonly accessed site for contrast injection. (clears throat) Excuse me. And also in that triangle,

you can see the veins that are also the preferred veins for IV cannulation, which is the cephalic vein, the median cubital, and the basilic veins. Why are they the preferred veins? Because they are accessible, they are visible, they are stable,

and they are large enough to accommodate large-bore catheters, and strong enough and large enough to withstand high-speed and high-pressure injections. How many of you here catch yourself unconsciously checking out other people's veins?

(audience laughs) Thank you very much (chuckles). I do that all the time in the subway. I make up stories in my mind how I can access that vein without a tourniquet and things like that. And I have come to realize that at this stage in my life,

diagnostic radiology and veins have become my thing. (audience laughs)

So needle guidance is one of the main tools that we use. This is basically a straight line overlay.

Distinct starting and ending points. We draw this again on cross sectional imaging. Automatically, you can align the C-arm to the, to kind of align with the path that you've drawn, in either a bullseye line of sight orientation, or also a kind of tangential view.

And really you can use this for anything that has straight line geometry. Bone trocars, cement cannulae, ablation probes, screws, temperature probes, hydrodissection needles, anything that more or less is straight line geometry. Just a couple examples of this.

On the right side you can see an example of bullseye needle guidance orientation, and then a more tangential view from the side of the same pathway, so that you can have real time kind of overlay guidance of needle placement as you rotate the II, with a detector,

back and forth real time. And one of the benefits of this is to be able to achieve placements within narrow corridors. Example on the left is placing a screw through a scapular body, which

you know, is pretty thin with a narrow corridor, but this really facilitates placement in this circumstance.

Alright, so I'll put that up there, so you have our contact information, and what questions do you have for us.

Stand up. Copy of the slides. Email us and we can send them. They will be on the web or on the app. Okay, because I did send them in.

You practically have everything from IR right there. You just don't have all the practice because when she talked about numbers, ours is currently eight pages. But as you can see, it's more meaningful than even eight pages that say vital signs.

So we actually have eight for IR at the moment. And so, I just didn't put all the practice ones on there. So you have most of them. You can reach out to me and I'll talk with you about the other ones. Yes ma'am.

(speaking off microphone) She's talking about the essence of a radiology nurse being a consultant. That actually is a phenomenal point, and it doesn't matter whether you're on a small institution or a large institution.

I regularly do classes for my floors on various different topics because of just that reason, and it is something that I'm kinda glad you brought up because we missed that with in,

but we could say it falls in with that communication because it is working with others and staff. So we could incorporate that in there, but that's a really good point. We are the resource. That is an essence.

We're the experts in radiology. Come on, how many of you still have nurses that come in, and we're told at nursing school, recent graduates told at nursing school that if you're allergic to selfish, you're allergic to iodinated contrast

please tell me no one in the room here believes that. And if you do, please come talk to me and we'll talk about the science behind that. Actually, I'll talk about the science real quick. Our thyroid gland needs iodine to function, so what are the odds of us

being truly allergic to something we actually need for our body to work correctly. Not saying it's impossible. I actually do know someone who's truly allergic to iodine, but it's incredibly rare and highly unlikely. So what other questions do you have?

Yes ma'am. What she's talking about is the preceptor that's lackadaisical and just signs off anything and the preceptor that is... And how do you bridge that?

That really gets into another presentation. It is real, but it gets into preceptor development. And that's why a lot of these, you'll notice it says per policy. So I can sit there and...

What's the hospital policy? If the hospital policy says you use chlorhexidine before you start a peripheral IV and they didn't use chlorhexidine, then they're not following policy to begin with, and then it gets into...

We talked about the employee being in the center. That then gets into... It's not a competency issue. It's a performance issue and it's a management issue. If you have an orientee

that's not following the policies and is then teaching the... I'm sorry, if you have a preceptor and is teaching the orientees to do things that don't meet hospital policy, then that's something your management team

needs to be aware of, because they need to correct those workarounds and those cheats that violate policy, because that's not necessarily a competency issue. That's a performance issue. This person is choosing not to.

- [Nikki] And I think we have the very similar question and conversation at our organization. So what deems that preceptor, quote unquote, to the next level of being competent in order to sign of an orientee. Is that kind of your question as well?

We are having those discussions because we are having the same kind of thought process. So, as Kristina mentioned, we are really relying on our preceptors. And so the next stage of this is to really kind of re-examine and revamp

some of our preceptors and say, "Okay, well, these are some of the criteria "that you need to be in order to be a preceptor "and not just the next person on the list "because you haven't done it in a year." So, some of the other general things,

like for restraints, because I sit on our restraint committee, we now have super users or trainers for restraints that have extra things that they are gonna need to be signed off and/or demonstrated in order to be deemed a trainer.

And so, we're working really closely with psychiatry to come up with some of those components and working with our clin specs and our NPs and things like that, so that we can say yes to your trainer or no and then again with our preceptors.

- [Kristina] And then ultimately, as I work on stuff with my preceptors, my managers don't know this yet, and one of them is probably in the audience. Sorry, Chris, surprise. Once we get some of the preceptor stuff down,

I then actually wanna make a preceptor introductory competency sign off that they can't be a preceptor until they have met certain criteria. And so, it is a step process, but that is one of the next places I'm looking to go.

Don't shoot me, Chris. Surprise. Any other questions? Enjoy the rest of your conference. Wait a minute, wait a minute. Nikki saw one.

Where was it? What she's talking about is somebody comes in and they have to be oriented to all the modalities, and they do two weeks in MRI, and two weeks in CT, and two weeks in nuclear medicine.

And some of the orientees aren't necessarily liking that flow. Did I get that? Okay. My thoughts on that is we have the same issue in gen rad, because I have to do the modalities.

First and foremost, we don't sit there and say it's two weeks here and it's two weeks here. We sit here and focus on goals. The first goal of orientation for general radiology is that you understand radiation. You understand the safety components of it.

You understand contrast. You understand where your emergency equipment is, and you can start IVs. They go to the area that does a lot of those things. They get signed off on those, and then we move them to the next step.

And for us, we use to have a lot of primaries and a few floats. We actual learned as staffing changed, having a lot of primaries for each of the modalities hurt us. Because then if there were some,

the flue hit, primaries couldn't do any place else because they didn't know it. So we actually have, for the most part, one primary for each modality or each practice area.

And then everybody else is hired as a float. From the start, that is the expectation of the job. It is made very clear to them from the beginning that you will be floating. And truth of the matter, most of our float nurses actually end up loving it,

because they don't get caught into the politics of a specific area. But then we also focus a lot on what's the same. So we start with the IV in the next area they go to. Because where we do IV,

it has CT, MR, nuclear medicine. We don't have to worry about the nukes there. It's just CT and MR. The next area has CT, MR, and... So we add, build on to each step of it. Yes, ma'am.

Yey! She is absolutely right. She said today is certified nurses day, so everybody should be very proud of that. If you are a CRN, go please see them at the RNCB table

and you can get this really cool pin that says you are a CRN. So CRN photo shoot upfront after this. After this. Any other questions. Go have your break.

Wait, wait, wait. - No, no, no. Please have a seat. We're not done yet, but you can applaud them because they were fantastic. Thank you so much.


According to the ACR 2017 manual, the incidence of contrast media extravasation

related to power injection has ranged from 0.1%, or that is one out of 1,000 patients, to 0.9%, which is one out of every 106 patients. Peripheral venous extravasations are usually caused by a dislodged or malpositioned venous catheter. It could also be caused by the leaking of contrast media

at the site of the injection, or a newly venipunctured site above that site of injection, and it could also be caused by a rupture of the vessel wall.

and stopping conduction. Just to finish up, a couple of nice cases. This one that we did recently, a guy had pleural plaques and had significant neuropathic lancinating pain

in his rib cage and you can see on the right hand side, we've brought the needle down underneath the ribs, so this is sort of a sagittal view on ultrasound of the rib. You go and target underneath the rib where the intercostal nerve runs. You do your diagnostic block.

We did that and the patient had significant improvement in pain, and then we come in behind that and do thermal ablation, so we're taking the RF probes and we're placing them in multiple intercostal nerves around where the patient's pain is

and you can see that we've marked on his skin the exact areas where he has profound pain. You can't even touch his skin without him having severe pain. And after we finished the thermal ablation, he still had pain, but he could rub his skin,

he could wear a shirt, he could do more things. That was definitely successful.

- [Kristina] Alright, everybody still awake, right? Alright. Sound familiar to some of you? Good. Alright, so what is the essence?

When we talk about the essence of a job, it's what makes a radiology nurse different from a med surg nurse. What makes a radiology nurse different from an OB nurse. If you've ever heard Donna Wright speak, she talks about the essence of something

that we took from her process. She'll tell you for an ICU nurse, one of the essence of an ICU nurse is you gotta have a little bit of a 'tude. Because the advocacy that you have to have for your patients is a little different than in med surg.

You could be a phenomenal med surg nurse, but not a be a great ICU nurse because you just can't stand to those physicians to say, "Ain't happening on my watch." So, but you have any successful ICU nurse who is not wiling to put his or her foot down

and say, "This is the way it's going to be." So, pull up our phones again, last time for this one, and what makes a radiology nurse a radiology nurse? What's specific to us? What specific knowledge, skills, behaviors

do we need to be successful radiology nurses? Independent is huge, flexible, safety. - [Nikki] Works in the dark. - [Kristina] Works in the dark.

Yes, you gotta be able to see in the dark. Scope of cares. Can do anything, who said that one? Yes! Collaboration. (laughs)

Okay. Those on my staff, development team, we're gonna have to find a way to add that one to ours. Multi-tasking, conscious sedation. You're absolutely right. And this, we did the exact same thing.

I sat down with both my gen rad staff and my IR staff and said this exact same question to them. And then these are kinda sort of the things,

the themes that came out of their brainstorming session. Environmental safety there is safety on the floor, but the floor doesn't to worry about an MRI magnet. The floor doesn't even realize

that the magnet is always on. It doesn't mean anything to them. It means a great deal to us. Nuclear medicine safety. Yeah, standard precautions for them, well it is for us, too,

but I'll be honest with you. I was doing nukes one day and I was doing a pediatric patient. We're doing a urinary study and I took his catheter out at the end, and this little boy decided he wasn't done peeing.

And it ended up right here. That is not necessarily a concern for a floor nurse. They don't have to take their clothes off and leave them at work because they've been peed on with radioactive urine. I had to do that.

If you ever worked in nuclear medicine, always keep a pair of change of clothes in your locker. Always. Shoes, too. Because I've also walked into a patient who has peed all over the floor

and it was in the dark. Now my shoes are radioactive and I can't walk around the rest of the hospital with them. So, shoes, too. Collaboration. That was one you guys mentioned.

Independence you mentioned. How many times are you the only nurse around? Attention to detail. Critical thinking. Again, you're the only nurse around in a lot of times. You don't have another nurse

to bounce things off of, so you have to have incredibly strong critical thinking skills. Flexible because things are constantly changing. Picking up the changes with little information. We're not floor nurses.

We don't have a chart this thick. When they come down to the lab, we're only looking at, the most recent labs, what meds have they had, and what's the diagnosis, and why are we doing this procedure.

We don't know the rest of the history. And in gen rad, you know less than that, because more often than not, the technologist has put them on the table, done their scan. They've had a contrast reaction and then you're just brought in.

You have no idea what meds they're on. You have no idea what they're allergic to. You're just responding to that symptoms and treating from there, problems solving, communication, assessment, monitoring, advocate for the patient,

responding to emergencies. We have to respond to emergencies a little bit different than the floors do, because again, we don't have the volume of people. If a code happens on the floor, every nurse on the floor is there to

lend a hand or try to help pick up the other patients while the code is happening. If it's Saturday morning and you're coming in on call, it's you, your tech, you might be lucky have an extra tech floating around, but probably not, and your radiologist.

And I mean no disrespect to our radiologist, but let me ask you, and you don't have to be honest if you don't want to. Who runs codes in radiology until the team gets there? We do.

Yeah. So, we have to have that knowledge above and beyond because our docs care about the procedure. They are care about the image. Yes, I actually was doing some mock codes,

and I sent out to our chief radiologist. We're gonna start including the physicians in our mock codes. Any problems with that? She wrote back to me, "Oh, I think that's a great idea.

"I'll gladly come and follow directions." And then I went to her and I said, "Hey doc, do you realize "that until a code team arrives, "you're running the code?" Uh.

So, medication administration. And as Nikki already mentioned learning on the fly, IR procedures change all the time, that the procedure we did today, we're not doing anymore because tomorrow we've got a totally different way to do it.

And so there isn't a way to orient you to that so much. So you've got to figure it out quickly. For us, our thrombolysis, the thrombolysis dressings, I've worked really hard on ongoing competences because my IR nurse has went thrombolysis dressing

on as an ongoing competency every year. When Nikki mentioned ongoing, you shouldn't keep repeating ongoing competency because if you've shown your competent, like riding the bike, you don't really forget. You don't necessarily lose competence.

You just need to refine it a little. And I finally got them to... You're coming in on call and you have that thrombolysis dressing, whatever competency we did for you six months ago, you're still not necessarily gonna remember

because you wanna do that thrombolysis dressing. There's enough nurses that you may do to a year. depending on the flow. You still have to know where your resources are. So do we have the resources in IR to tell you how to do a thrombolysis dressing

if you don't know. And if we don't, we need to add that. And then when we have it, where is it? Can you find it?

Radiologic contrast agents have properties that categorize them as vesicants, and I would like to discuss two

of its clinically relevant properties. First is osmolality. Osmolality describes the concentration of a solution. It is the ratio of solute to solvent, and on the screen here, I am going to show you the osmolality of blood, of plasma,

as opposed to the osmolality of the contrast media. The reference range of serum osmolality is 275 to 295 milliosmoles per kilogram. And we have the high-osmolar contrast medias, which we know as the ionic contrast, has an osmolality

of 1,400 to 2,000 milliosmoles per kilogram, which is five to eight times more concentrated than that of plasma. We have our non-ionic contrast, or the LOCMs, which is 600 to 800 milliosmoles per kilogram. This is what we use at our institution.

It is two to three times greater than that of plasma. And we have the iso-osmolar, or the non-ionic dimers, which has approximately the same osmolality or concentration than that of plasma. Now when a solution is highly concentrated, it is thicker, which brings us to the next clinically relevant property

of contrast media, which is viscosity. Viscosity is the measure of the resistance of fluid. And I googled this, in simple terms, it is the measure of fluid's thickness. The thicker and more viscous a solution or a contrast media, the greater the force it will need

to be administered into the patient's body. It is almost like injecting syrup into the patient's veins. It is this viscosity that causes vein spasm and discomfort along the site of injection.

So now I'm gonna take you through our journey of how we came up with our introductory competencies. So, it can be very overwhelming when you're implementing this into your organization. So, what we did, Kristina and I, led a group to work on introductory competencies

and really taking that checklist down to just a couple pages. So we went to eight pages, generally speaking, from the 23 pages. And then her radiology specific might even be a little less. So, the first thing that we did was we gathered nurses

from all over all different disciplines. We had medicine, surgery, pediatrics, OB, et cetera. And so we all got into a room with a whole bunch of white boards, post-it pads, and got all of their knowledge together. So the next thing we did was a literature review

to see what competency models are out there. Has anybody here done the lit review or use specific competency framework in your organization? A couple hands. So if you're not familiar with Donna Wright. Donna Wright is probably the most talked about name

when you're looking through competencies and we've actually adopted her for our ongoing competencies. As we were looking through to do our introductory competencies, it wasn't just the exact mold that we wanted.

However, one of her main premises is really as Kristina said in the beginning looking at interpersonal, your critical thinking, and then in addition to your technical skills. So your technical skills are going to be,

"Can you take vital signs? "Can you insert an IV? "Can you give contrast? "But interpersonally, can you speak with the physicians, "or the tech, or the patient?" And then critical thinking,

so if you're in an emergency situation. So a lot of our introductory competency is really focused on technical skills and don't have these other domains. And so we thought it was very important to bring this

tenant of Donna Wright into our introductory competencies. What's that? (speaking off microphone) Oh yes. Kristina just reminded that

the employee is at the center of all of these domains, and that is super duper important. Because one of the most prevalent things that it does is put the accountability back onto the employee to ensure that the competencies are getting finished. So that we're not handholding and running around

and saying, "Did you do this? "Can you do this appropriately?" And so they need to demonstrate to us that they can do these things. So, the next thing that we did was we looked at the Carrie Lenburg, the COPA model.

And so, the COPA model basically has eight high-level core competencies that can be used for any particular nurse coming in any kind of practice environment. And so, these are the eight core competencies that COPA or Carrie Lenburg

is the author of this model. And so, what we had done was we had all of our nurses from our practice environments go up on a white board and we wrote down what are the things that are essential for all nurses.

So, regardless if you're an OB or if you're in the ICU, or if you're in med surg, neuro, oncology. And so, when we were finished, we had about 200,

220 things listed on the board. And it was like, "Oh my goodness. "We don't need 220 core competencies." But as we started to loo through those, we saw some kind of trends and themes,

and we said, "Okay, how can we narrow "these particular things down." And so, that is what we did. So we got the minimal skills and knowledge that we thought all nurses needed to do. Alright, so my question to you.

Again, if you go back to your Poll Everywhere, you shouldn't need to do anything from when you've texted before, you can just text back. Keeping in mind, generally speaking, not radiology specific

or IR specific or anything like that. So what is something that you think all nurses need to know regardless of their practice environment? Communication, bingo. Advocate is huge.

Med admin, yeah. Assessment. They're going so fast. These are great. - There was a lot of communication ones. - [Nikki] They must have been paying attention to our...

(speaking of microphone) So these are really great, and these look very similar to the ones that we had also come up with on our whiteboard. Perfect, yes.

So, and if you keep in mind, these are a lot of things that the nurses, when they have a license, should already know when they come in. So you're really just validating that they have these particular skills.

So what we did, like I said, is after we had all of our 200 things on the board, we kind of narrow them down based upon our themes. And so, for us at Johns Hopkins, we came back with four. We narrowed 200 down to four.

Practice communication which we just saw very heavily in the previous slide. And then safety QI EBP, because we're an academic teaching institution and we really rely on that for our staff, and then our core values.

And our cor values really are aligned with the core values and the mission of our hospital. So those are the four that we came back with. So from there, what we were able to do was take those 200 things

and kind of then layer them out very specifically as you just saw. Somebody had written med admin and assessment. And so these are some of the things that we have. So demonstrates and documents head to toe assessment. Demonstrates tolerance and respect for others.

So that would fall under our core value. Follows infection control practices. That could be our safety QI EBP, and then identifies own learning needs. And so, one of the things as we go back to our meaningful

and then narrowing down our checklist is a very good competency learning on the fly. You're not gonna teach that orientee every single thing that they could possibly ever see in 90 days or six months. So do they have the competency of learning on the fly

that they have a patient come in that they have never taken care of? Do they know how to use their resources and figure out on their own how to appropriately take care of this patient? And so that's one of the things

that we really felt very strongly about adding. And so one of the last things that we did was then we went out to our specific departments. We went out to OB, we said, "What's specific about being an OB nurse "that could exemplify and continue on

"with our competency statements? "What is it that means an ICU nurse "that's very specific to them?" and then more importantly, "What is very specific to be a radiology nurse. So, I'm gonna turn it back to the radiology expert

since that is not me.

So documentation, before I show you these next slides, there are a couple of things I wanna make you aware of.

As Cathy said, she has no introductory competencies. Hopefully there is no one else that's in that same ball of wax. But Joint Commission does require a couple of things in their competency forms. They do require that the employees name is on there.

They want a description of the competency, an identification of the verification method and the signature of the person validating and the date it was completed. Then this does need to be maintained as part of the personnel record.

So remember that 23-page checklist. This is the first page of our introductory competencies for IR. And you will see our hospital came up with those four core competencies.

So this is the first page of the practice, core competency. And those core statements, we took those core competencies and made overarching headings for those. The five that we came up with from a nursing perspective,

oops sorry, demonstrates and documents vital signs accurately and appropriately, demonstrates and documents head to toe assessment, administers and documents medications accurately using the five rights,

and appropriately responds to patient condition. Those are the things that the hospital says... Whoa, what did I hit? Okay, sorry about that. Those are the things that hospital nursing said is the key elements of practice.

So then when we met as my radiology team, how do we demonstrate and document vital signs? Well, our checklist, our old checklist, had temperature. Oral, rectal, axillary, tympanic.

Okay, how many of our nurses graduate in nursing school? All of them. So, was temperature oral, rectal, axillary, tympanic

all part of fundamentals of nursing? Could they have graduated nursing school if they could not take vital signs? Absolutely not. So why do we have a list that says oral, tympanic, and all of those things.

It's ridiculous. So instead, we looked at what we do in IR. In IR, can you use our monitors? That's where the competency is. So, independently places the procedure required assessment, equipment.

And we actually changed this a little, so it's more consistently places required. So we've changed this a little bit. Including correct alarm settings. That's what matters. And I'll tell you we didn't spell them out

because things change. Example, admittedly we're not doing capnography in the IR lab at the moment. It actually is an equipment issue tat we are actively working on fixing. So if I had put everything in there

and didn't include capnography and then three months from now, then I'd have to go change it. And I have a lot of work to do. I don't need to just update for everything. So we want these statements somewhat broad.

But if you were a Joint Commission inspector that came in and wanted to know if my new hire was competent in doing vital signs. Would this give you an idea without seeing a check mark next to blood pressure standing, sitting, lying,

left arm, left leg, right leg. It tells me everything I need to know. Head to toe assessment. We had to alter this a little, because we put as appropriate to procedure. Because in all honestly,

how often do we do a full head to toe assessment? We don't. So why should I be checking my nurses off for absolutely everything if it's not relevant to what we do. So it's focusing on the relevancy,

but we have a neuro IR so part for that for neuro IR absolutely includes a neurological assessment. That is big for them. And skin, we do care about skin to some extent, but we only care, are we positioning them in a way

that we're gonna cause some sort of friction burn from the way we're positioning them or they're gonna get radiation burn because of the way they're positioned and how they're being scanned. That's what we care about the skin,

care to the detail. The floor nurses have to put every scare and every... We don't care. Five rights of medication. Responding to patient condition. I will tell you, on this, it only says

catheterize the patient as per policy. There is a few more pages to the practice version of this. And what we did with the procedures for example. I went through with my team and I said, "Okay. "What procedures does an orientee

"actually have to physically experience "and be part of and be somewhat comfortable in "before they can come off orientation?" And I don't have it in this presentation, but then there is a list. And then we have the other ones that if they get great,

but we know we only do IPSS, inferior petrosal sinus sampling, five times a year. The odds of an orientee getting that is next to impossible. So, we can't expect them to do that. So that then comes to our validation methods.

You see all those 11 methods are up here. So for this, the only way we're allowing them to sign off on these is direct observation. So that evidence of daily work. We have to see them do this. But when you look at head to toe assessment,

it could be signed off because we've watched you do it. It could be signed off because we've done a mock scenario. So we've sat here, and Nikki comes in, and we're gonna do, she's here for a stroke.

Let's go through and talk through her neuro assessment, or the case scenario where the patient is coming in and they can't lift their left arm. What is are assessment of those?

Sorry, I keep hitting the buttons. And then you see exemplar. Exemplar, how many of you hire new grads in IR? Okay, there's a couple and there's a push to more of that. But in general that doesn't always happen.

So if I have, and it is in here, if I have emergency response, you may not have an emergency during orientation, but can that orientee sit there and say "You know, we had this code in my last job,

"and we did, this is what the scenario was, "and this is what happened, and this is what I did." And you still know when they tell you that they started with compressions. Great. That's what they're supposed to be doing.

If they tell you they started with airway and the patient was dead, you know that's not current BLS standards. So you can kinda judge, are they competent? Are they following the approved standards. The next overarching was communication.

Here's our communication ones. A lot of these were actually based from the hospital, but demonstrates tolerance and respect for others using courteous and caring behavior. That is the entire competency statement, overarching statement for every nurse in the hospital.

That's what communication means. How do we do it in IR? Oral and written, documentation in EMR demonstrates acceptable institutional department guidelines

for professional use of IT resources. So, are we finding that our orientees are on Facebook, why they're supposed to be monitoring the sedated patient. If they are, they're not showing competency because one of the lectures yesterday talked about

being distracted. Huge distraction, really easy to miss things that way. They have a whiteboard that tells them what's going on in their area for the day. So do our new orientees know that, that whiteboard exist, what it is, how to use it,

that's what we're looking for with them. Safety quality, improvement in evidence-based. Some of these are some of your standards. You know where your firepools are. Joint Commission likes to know, your staff knows where these things are.

The rooms are cleaned appropriately, following whatever your hospital's HIC cleaning policies are. But then you see the ones that are really specific that you won't find any place else in the hospital. Consistently follows standard of care

and policy to minimize radiation exposure to self, patients, visitors, and other staff. Consistently follows... There's a button on the back. That's what I keep doing. That's why I keep going backwards.

Consistently follow standard of care and policy to maintain magnet safety. - [Participant] You learn on the fly. - [Kristina] There you go. See how important learning on the fly is. If you redo your competencies,

please make sure every single competency sheet has learning on the fly. And follow standard of care and policy to minimize exposure to radiopharmaceuticals. I mean that is big in what we do. Then the core value

tie back in the Hopkins core values. What the larger group came up with was collaborating with the patient family and healthcare team to provide patient care in a healing and caring manner, prevent positive image of...

That should be of, not off. Of Johns Hopkins Hospital through professional appearance and behaviors. And here's our introductory competencies. Identify own learning needs and steps and resources needed for meeting those needs.

So demonstrates the concept of learning on the fly or just in time education to find information needed for at least three patient skills, patient populations or procedures that were not experienced and orientation. So if that

person never saw venous vein sampling, then they have to be able to tell us who can I talk to, where's the resource material, and what am I going to do if the six months after I'm off orientation, I'm now assigned to the room that has venous vein sampling.

So we want to see. Again, we're not gonna see everything, but we've asked them to do this three different times. So we kinda sorta know they understand the importance of knowing what I don't know and finding it out.

Now let us go to, let's talk about preventing extravasation, the role of the nurse. I am shaking. (audience laughs) Our objectives are to identify the risk factors for contrast media extravasation.

We are going to discuss the nursing considerations in access selection and power injection of central venous access devices, as well as peripheral venous access. We are going to review the determination of a Mediport's ability to be power-injected,

as well as the management of non-power-injectable ports in CT. Ammeruth will also discuss the prevention and management of contrast extravasations.

- [Nikki] Good morning everybody. Thank you so much for having me and thank you Kristina. So, I am going to talk to you more about the very broad high level

more than just the radiology kind of competencies. Competency should be assed for all employees at three main stages. So when they're hired, which would be typical of an HR. In our department, it's career services

or nurse requirement. And that really just makes sure that folks have the things that they need in order to get their job. Do they have a nursing degree? Did they successfully passed and have a license.

Do they have CPR? Things like that. And so, those are all done before somebody is hired. The next stage is in the introductory or sometimes known as initial.

And that is usually done in the orientation phase, so when they first start through the end of their orientation. And this really just focuses on the essence of their job. And then the last stage is their on-going. So these are done every single year.

They change every year. They're fluid and they're dynamic, and then they can be very specific to the person's role or they can be very generic in, that they need to practice patient safety, hand hygiene, things like that.

So, for today's purposes, we are gonna focus on specifically the introductory phase. So many of you, I'm hoping, already have some kind of ongoing competencies outside of your required education. And if you don't, you can certainly come

and talk with Kristina and I about that. But for today, we're gonna focus on our introductory. And so, as I said, those are unit-based and they're very specific to the particular unit, because their work required for a nurse or a tech or somebody to practice independently

once they're off of orientation.

as well as the chemical. In thermal RFA, the target is to get the nerve to 70 to 90 degrees, which basically then disrupts the axonal continuity.

You get this Wallerian degeneration of the nerve because you disrupt the myelin, and the axon, and the endoneurium. Basically you're doing what the surgeon does by basically stopping that conduction of the nerve. Pulsed RFA is a newer way of addressing this

and this is not entirely well understood. Basically you're doing a non-lethal ablation affecting what's called modulations. You're modulating the nerve by passing an electric current across the nerve. And what that's supposed to do is reset the nerve.

There's actually genetic changes that occur in the dorsal root ganglion based on doing this modulation. I will tell you that if I ask my colleagues on this esteemed panel, how does pulsed RFA work, they would all give me kind of funny looks, I suspect. Because it really isn't totally understood right now.

Cryoablation is similar to thermal RFA where you basically are damaging the nerve

Our next nursing consideration is our documentation of venous access site. We document the gauge and length of the catheter we use, and the location of the IV site.

We also document the attempts made by the nurse, because in our guideline, no more than two attempts should be made by one nurse, because multiple attempts would lead to delay in the study, it would give patients unnecessary pain, and of course, it limits the future venous access.

This is also the same documentation we use when we access Mediport for contrast media injection. We have to confirm the Mediport first, if it's power-injectable or not, and also we have to document the tip location. We also have to verify patency,

we have to make sure that the access flushes freely, the site is non-tender, and there's no signs of infiltration noted.

Before we give the contrast,

it's our responsibility to warn the patients to report any unusual sensations at the IV site immediately, such as if the patient complains of any pain, like stinging or burning pain, any feeling of tightness or pressure in the IV site, that would indicate contrast extravasation already.

During contrast injection, we have to observe the IV site for at least the first 10 to 20 seconds of injection. We have to look for any redness, any swelling, and you have to palpate the injection site. So a strong, palpable thrill

would indicate a good contrast delivery. And if there's any sign of extravasation, we have to stop the injection of contrast right away.

And this is interesting that since 2000, this paper, there's came out is Anesthesia Practice and Clinical Trends in Interventional Radiology. Even in 2000 they were saying there's a rapid growth of IR.

And we kept on sayin' that, and sayin' that, and sayin' that, but it's finally here. You know the procedures are so complex. And me bein' down in IR, and I say down in IR because see, this is me talkin' about we're up in the clouds,

and IR for us in the basement. But it's not, it's really not. It's actually on the second floor. And we're on the forth, third floor. That's all the difference. But it seems like another different world.

But the things that we're able to do, that the radiologist's are able to do, the IR team's able to do with very sick patients is amazing. I mean you know, treating cancer percutaneously. You know, pain issues.

The services that are rendered are very, very impressive. I'm very amazed and I'm happy actually to be involved. So we can see the procedures are more complex, more time consuming. The patient populations keeps on getting sicker and sicker.

And from the previous presentations we've seen that a lot of the slides start with a patient, non surgical candidate. Patient non surgical candidate. So you know they're very sick. And then the next question is like,

okay so what kind of support do they get? Can they lay flat? How's their heart? Is it barely beating? you know, they have a tomato for a heart. Or not.

But these is a study of the amount of off site anesthesia cases that are bein' done. And you can see since 2010 to 2014 the trend is increasing. So now we're up to like 40%. And that's nationally.

So, some of the key points.

Competencies is the transfer of knowledge into practice. Required education is not the same thing as a competency. Competencies have to be meaningful. Not just those little check, check, check, check, check, check, check. They need to address all three domains of competency.

And if you looked at some of those, we actually did have those things. Now some people say communication is part of practice. What is the number one cause of medical error? Communication break down. We decided communication

was so incredibly important for that fact alone, that that's why communication is actually separated out on its own. We wanted to make sure people understood this was the key to a safe environment. Introductory competencies

focus on the essence of the job and you use a lot of different verification methods to verify the competency. And ultimately, sometimes a skills checklist is appropriate, but skills checklist realistically by definition is not respiratory therapy,

trait care, inner cannula, outer cannula. That is not a checklist. A skills checklist by definition sits there and says they do,

start an IV. They gather all their supplies. They wash their hands. They identify their patient. They tell them what they're doing. They select the appropriate vein.

They clean it using whatever policy your hospital says it's supposed to be cleaned with. They get their vein. They secure it. That's a checklist. This competency checklist that we're using for new hires,

these skills checklist, they're not skills. There's not a checklist. The checklist tells you what behaviors you're looking for. And please don't get me wrong, checklist don't go away. They are still important.

But if you really wanna know that your employee is competent, you need to look at what do you want out of them.

So, competencies are really supposed to be meaningful. In our hospital, we had tons of competencies or an orientation skills checklist, and it was very lengthy,

and it was one-word statements, maybe just a couple phrases. I'm gonna list out every single thing that everybody needed to do. So I would like everybody to stand up. I know it's morning, we all had our coffee.

Everybody standup. You all get to sit down in a minute, I promise. Alright, so, if your organization has a competency or an orientation skills list and it's more than 20 pages, stay standing. Wow.

All right. Okay, so one more time, everybody back up. Sorry about that. Everybody back up. Alright, so now we're gonna do the reverse. If your organization has an orientation skills list

and it's more than 20 pages, go ahead and sit down. Alright, so if it's more than 15 pages, stay standing. So if it's, let's say if it was less than 15 pages, stay standing. If it's more than 15 pages, sit down.

- [Kristina] So, 15 to 20 range? - [Nikki] Yeah, 15 to 20. Alright, if your orientation skills checklist is less than 10 pages, stay standing. Wow, these guys are good. Alright, if your orientation checklist

is five pages or less, stay standing. My goodness, we need to find these people. - [Kristina] Well, honestly, to be really fair, a handful of them are my staff. (laughs) - [Nikki] Okay, so, next thing

if your orientation skills checklist is two pages or less, stay standing. Alright, so we need to find and talk with you at the end because that's what we need. And then everybody else in the room, you need to find them at the end.

Wow. Applause for you. - [Kristina] No, no, no. - [Nikki] Oh you don't have one. Oh, no, no.

Okay, I take the applause back. Alright, so we definitely need... - [Kristina] You need to find us, Kathy. - [Nikki] The other way around. So when we started this journey, our orientation skills checklist was reaching 23 pages.

And that, in my opinion, doesn't mean anything, it just means at some point or another somebody heard the topic during their orientation. They may have just a one-on-one discussion when they couldn't get through, and they just had to sign that off

in order to meet the joint commission requirements. So this is an example, very high level, of something that would be on one of our orientation skills checklist. So, if you read through there, does that tell you if I'm competent?

Does that tell you that I practice safely that I can do these things? It's more of a yes or no, but you don't know how to validate that, or you don't know how good I could really be at that. So this is an example of how we transform

those very long list into something that's a lot more meaningful. And if you notice, it went from seven lines of text down to four. So while it's more meaningful and gives more insight

as to how a practitioner could be deemed competent, it's also a lot shorter. All right. So how many of you in here know how to ride a bike or at least knew how to ride a bike when you were a kid.

Alright, me. So, I have not ridden a bike in a very long time, about 10, 15 year. And so, as I was teaching my son how to ride a bike, I was like, "Here, let me show you." So I got on the bike and I'm like, "Oh my goodness."

One, I'm a lot more scared and my fear factor has gone up, but number two, I was very shaky. But after about five, 10 minutes, you knew that you have to put your feet on the pedals, you knew you needed momentum in order to keep going,

and so I could then ride a bike. So I was very shaky. For all of your new hires to come in, at some point, they have passed some kind of licensure, they were deemed competent, they passed the boards, they took a fundamental or a transitions course,

they know how to take vital signs, they have a license. We need to give them credit for things that they should have already experienced. When I look around in this room today, everybody has a shirt one, your arms through the armhole,

at least I think so. Everybody has appropriate pants or skirt or dresses on. I don't need to have a 10-list page of can-put-shirt-on, can-put-pants-on. I'm assuming you have under clothes on. We'll add that on the list.

But what I can mostly say is that everybody is competent that you showed up here dressed appropriately today. Okay. So, just kinda just some other examples that we give.

So now we go to nursing considerations when power-injecting contrast media.

First is assessment of patient's risk factors to contrast complications. We have to assess if patient is at risk for an allergic reaction, so for patients who had previous allergic reaction, we have to make sure that they are properly pre-medicated

before we give the contrast media. And for patients who have a diagnosis of active asthma, we have to be very vigilant when giving contrast media to these patients, because they can go into bronchiospasm. We also assess our patients,

if they are at risk for contrast-induced nephropathy, so for patients who are diagnosed with any kidney disease and diabetes, we have to check for their recent EGFR to make sure that their kidneys are functioning well before we give the contrast.

And of course, we have to assess our patients, if they are at risk for contrast extravasation. Maria already spoke to you earlier regarding the risk factors, patients who are elderly, patients who have history of contrast media extravasation,

and patients who have poor venous access, are all at risk for contrast extravasation.

- I want to thank the organizers for putting together such an excellent symposium. This is quite unique in our field. So the number of dialysis patients in the US is on the order of 700 thousand as of 2015, which is the last USRDS that's available. The reality is that adrenal disease is increasing worldwide

and the need for access is increasing. Of course fistula first is an important portion of what we do for these patients. But the reality is 80 to 90% of these patients end up starting with a tunneled dialysis catheter. While placement of a tunneled dialysis catheter

is considered fairly routine, it's also clearly associated with a small chance of mechanical complications on the order of 1% at least with bleeding or hema pneumothorax. And when we've looked through the literature, we can notice that these issues

that have been looked at have been, the literature is somewhat old. It seemed to be at variance of what our clinical practice was. So we decided, let's go look back at our data. Inpatients who underwent placement

of a tunneled dialysis catheter between 1998 and 2017 reviewed all their catheters. These are all inpatients. We have a 2,220 Tesio catheter places, in 1,400 different patients. 93% of them placed on the right side

and all the catheters were placed with ultrasound guidance for the puncture. Now the puncture in general was performed with an 18 gauge needle. However, if we notice that the vein was somewhat collapsing with respiratory variation,

then we would use a routinely use a micropuncture set. All of the patients after the procedures had chest x-ray performed at the end of the procedure. Just to document that everything was okay. The patients had the classic risk factors that you'd expect. They're old, diabetes, hypertension,

coronary artery disease, et cetera. In this consecutive series, we had no case of post operative hemo or pneumothorax. We had two cut downs, however, for arterial bleeding from branches of the external carotid artery that we couldn't see very well,

and when we took out the dilator, patient started to bleed. We had three patients in the series that had to have a subsequent revision of the catheter due to mal positioning of the catheter. We suggest that using modern day techniques

with ultrasound guidance that you can minimize your incidents of mechanical complications for tunnel dialysis catheter placement. We also suggest that other centers need to confirm this data using ultrasound guidance as a routine portion of the cannulation

of the internal jugular veins. The KDOQI guidelines actually do suggest the routine use of duplex ultrasonography for placement of tunnel dialysis catheters, but this really hasn't been incorporated in much of the literature outside of KDOQI.

We would suggest that it may actually be something that may be worth putting into the surgical critical care literature also. Now having said that, not everything was all roses. We did have some cases where things didn't go

so straight forward. We want to drill down a little bit into this also. We had 35 patients when we put, after we cannulated the vein, we can see that it was patent. If it wasn't we'd go to the other side

or do something else. But in 35%, 35 patients, we can put the needle into the vein and get good flashback but the wire won't go down into the central circulation.

Those patients, we would routinely do a venogram, we would try to cross the lesion if we saw a lesion. If it was a chronically occluded vein, and we weren't able to cross it, we would just go to another site. Those venograms, however, gave us some information.

On occasion, the vein which is torturous for some reason or another, we did a venogram, it was torturous. We rolled across the vein and completed the procedure. In six of the patients, the veins were chronically occluded

and we had to go someplace else. In 20 patients, however, they had prior cannulation in the central vein at some time, remote. There was a severe stenosis of the intrathoracic veins. In 19 of those cases, we were able to cross the lesion in the central veins.

Do a balloon angioplasty with an 8 millimeter balloon and then place the catheter. One additional case, however, do the balloon angioplasty but we were still not able to place the catheter and we had to go to another site.

Seven of these lesions underwent balloon angioplasty of the innominate vein. 11 of them were in the proximal internal jugular vein, and two of them were in the superior vena cava. We had no subsequent severe swelling of the neck, arm, or face,

despite having a stenotic vein that we just put a catheter into, and no subsequent DVT on duplexes that were obtained after these procedures. Based on these data, we suggest that venous balloon angioplasty can be used in these patients

to maintain the site of an access, even with the stenotic vein that if your wire doesn't go down on the first pass, don't abandon the vein, shoot a little dye, see what the problem is,

and you may be able to use that vein still and maintain the other arm for AV access or fistular graft or whatever they need. Based upon these data, we feel that using ultrasound guidance should be a routine portion of these procedures,

and venoplasty should be performed when the wire is not passing for a central vein problem. Thank you.

that we can verify competencies.

If you look through this list, we don't even have checklist listed here, which I think is super interesting. The other thing, we use more of these than we do some other methods. So like our return demonstration,

or our testing, or exams are really popular ways that we can measure somebody's competence, but we don't very often use the evidence of daily practice. So if Kristina was my new orientee and I am her preceptor, and I am watching her gift contrast,

I can see through her evidence of applicating the contrast to the patient that she's either competent or need some risky areas that she need some work on. And so I can sign her off according to that. I don't need to do all of these methods

and just go back through a checklist. The other good thing about here is audits and documentation. So a lot of you I know are quality improvement and we have some auditors. And so we can get some really good data from them,

and so we can also have them do some work, and that's also really important when we're doing our ongoing competency so that we can pull that QI data and really identify the high-risk areas that the staff need to focus on.

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