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Safety Program, Teamwork, Resource Management, Lean Management | Safety in the IR Suite: A Collaborative Approach
Safety Program, Teamwork, Resource Management, Lean Management | Safety in the IR Suite: A Collaborative Approach
chaptercommunicationdelaysdoseseducateerrorsimaginginjectionlabelinglidocaineloopmeasurementNoneoutcomesoutlierspainpatientpatientspeerphysicianphysicianspoorproceduresradiationradiologyreferringsatisfactiontech
The Dashboard Implementation | Innovation and Application of Real Time Nursing Dashboards
The Dashboard Implementation | Innovation and Application of Real Time Nursing Dashboards
applyappointmentassessingbufferchaptercheckedinterpretlatemetricsminuteminutesmodelNonenursenursesnursingpatientpatientspendingproceduralradiologyscheduledtimetotalutilizationworkup
Delay Dashboard | IR Lean Sigma Team Improves Patient Experience and Throughput
Delay Dashboard | IR Lean Sigma Team Improves Patient Experience and Throughput
centerchaptercodingcolorcoordinatorcustomdatabasedelaydelaysdisplayedInterventionsNonepatientphysicianprepreasonstechupdatedworkflow
Non-Invasive Ventilation | Respiratory Compromise: Use of Capnography During Procedural Sedation
Non-Invasive Ventilation | Respiratory Compromise: Use of Capnography During Procedural Sedation
accurateairwaychaptercircuitcolorconsistentcpapdatadevicesdistaldistallyleaklevelliterlitersmaskmonitoringnasalNoneoraloxygenationpatientpatientsportprettysamplingstentsupplementalvaluesventilationventilator
Compassion | Gold Medal Lecture - Health of Technologists and Nurses and the Role of Compassion in an AI Focused World
Compassion | Gold Medal Lecture - Health of Technologists and Nurses and the Role of Compassion in an AI Focused World
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Staff Requirements & Education | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
Staff Requirements & Education | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
absorbablechapterchecklistdepartmenthazardMRINonenuclearpatientpharmaceuticalradiationradiologyremovesafetytechnologisttrainingzone
Research and Literature | Respiratory Compromise: Use of Capnography During Procedural Sedation
Research and Literature | Respiratory Compromise: Use of Capnography During Procedural Sedation
airwayanalgesiaanesthesiaanesthesiologybreathingcausativechapterclaimsgastroenterologyhypoxicimaginglocationsmedsmonitoringNoneoximetrypatientprovidersremotereversalsedationsupplementwaveform
Practice Guidelines | Procedural Sedation: An Education Review
Practice Guidelines | Procedural Sedation: An Education Review
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Q&A- Documentation, Before and After results, Leadership, Culture | Innovation and Application of Real Time Nursing Dashboards
Q&A- Documentation, Before and After results, Leadership, Culture | Innovation and Application of Real Time Nursing Dashboards
accomplishchapterculturedatadocumentationdocumentinginterventionalleadershipmanagermodalityNonenursenursesnursingpatientphysiciansprojectprojectsradiologyroundingteamtechnologisttechnologists
Signs of Burnout | Burnout in the Radiology Setting?
Signs of Burnout | Burnout in the Radiology Setting?
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Project Interventions & Improvements- Intake | IR Lean Sigma Team Improves Patient Experience and Throughput
Project Interventions & Improvements- Intake | IR Lean Sigma Team Improves Patient Experience and Throughput
anesthesiaattendingscallscenterchapterclinicalcliniciancoordinatorimplementedinsuranceintakeInterventionslabsNoneoutpatientpatientpatientsschedulesinghtriagetubeworkflow
MRI Safety & Screening | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
MRI Safety & Screening | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
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Project Interventions & Improvements- Lab Reduction | IR Lean Sigma Team Improves Patient Experience and Throughput
Project Interventions & Improvements- Lab Reduction | IR Lean Sigma Team Improves Patient Experience and Throughput
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Practice Guidelines | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
Practice Guidelines | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
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How We Established our Practice Guidelines | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
How We Established our Practice Guidelines | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
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Q&A Uterine Fibroid Embolization | Uterine Artery Embolization The Good, The Bad, The Ugly
Q&A Uterine Fibroid Embolization | Uterine Artery Embolization The Good, The Bad, The Ugly
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Q&A Bleeding Risks | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
Q&A Bleeding Risks | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
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The Path Forward | Uterine Artery Embolization The Good, The Bad, The Ugly
The Path Forward | Uterine Artery Embolization The Good, The Bad, The Ugly
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Factors Contributing to Hypoventilation | Respiratory Compromise: Use of Capnography During Procedural Sedation
Factors Contributing to Hypoventilation | Respiratory Compromise: Use of Capnography During Procedural Sedation
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Clinical Workflow for PET/MRI | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
Clinical Workflow for PET/MRI | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
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Q&A PET/MRI  | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
Q&A PET/MRI | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
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Project Interventions & Improvements- Team Empowerment | IR Lean Sigma Team Improves Patient Experience and Throughput
Project Interventions & Improvements- Team Empowerment | IR Lean Sigma Team Improves Patient Experience and Throughput
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IR Outpatient Delays | IR Lean Sigma Team Improves Patient Experience and Throughput
IR Outpatient Delays | IR Lean Sigma Team Improves Patient Experience and Throughput
chapterdatadelaydelayeddelaysNonepatientpatientsreasonsscheduled
PET/MRI vs PET/CT | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
PET/MRI vs PET/CT | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
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Introduction to Establishing Periprocedural Screening Guidelines to reduce bleeding risk associated with Image-Guided Theraputic and Diagnostic Procedures | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
Introduction to Establishing Periprocedural Screening Guidelines to reduce bleeding risk associated with Image-Guided Theraputic and Diagnostic Procedures | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
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Project Interventions & Improvements- Prep & Pacu  | IR Lean Sigma Team Improves Patient Experience and Throughput
Project Interventions & Improvements- Prep & Pacu | IR Lean Sigma Team Improves Patient Experience and Throughput
chaptercolorcoordinatordelaysdisastrousNonepatientprepregistrationthroughputtimewaiting
Background to the Project- Challenges | IR Lean Sigma Team Improves Patient Experience and Throughput
Background to the Project- Challenges | IR Lean Sigma Team Improves Patient Experience and Throughput
challengeschapterdelayeddelaysfeedbackinpatientjonesNoneoutpatientpatientpatientsproceduresquantifyreportschedulescheduledsurveys
Q&A- Procedural Sedation | Procedural Sedation: An Education Review
Q&A- Procedural Sedation | Procedural Sedation: An Education Review
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Q&A Improving Patient Delays | IR Lean Sigma Team Improves Patient Experience and Throughput
Q&A Improving Patient Delays | IR Lean Sigma Team Improves Patient Experience and Throughput
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Radiation Protection | Gold Medal Lecture - Health of Technologists and Nurses and the Role of Compassion in an AI Focused World
Radiation Protection | Gold Medal Lecture - Health of Technologists and Nurses and the Role of Compassion in an AI Focused World
bindbreakschapterdamagedecreasednadoseexposurehumansleadmutationsNonepatientsphysicianspreventradiationradicalsscatterunderestimatevaries
Patient Education PET/MRI | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
Patient Education PET/MRI | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
assesscervicalchaptercontrastdiabeteslymphMRImrisneuroendocrinenodesNoneoncologypatientpatientspelvicperfusionphysicianreferegimenresumetreatmenttumors
Transcript

some of the things that organizationally

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Thank You Alyson so my name is Andrew Denver and one of the radiology residents in our ESI our program and I'm

the technology lead for our delay dashboard which you can see pictured here as was mentioned this is a key tool in our effort to improve the outpatient delay times we implemented this custom piece of software and the main benefit

it provided us one of the main benefits on top of our EMR was enabling us to track patient case status and delays in a real-time it consists of a dashboard with a web front-end that is visible just by typing in the URL that's

maintained by some of our tech savvy residents and fellows one of the the big things we like about the dashboard is the fact that we developed this color coding scheme as you can see in the key here that color coding scheme not only

allows us to kind of at a glance see how the day is running but also is used to trigger certain interventions when patient case delays reach a certain point so for example I the ideal world all of the cases are green with a smiley

face that doesn't happen so at a case turns yellow which is the delay of 15 minutes or more the prep nurse will acknowledge the delay to the patient and promise to keep them posted when a case turns orange which does delay of 30

minutes or more the prep nurse and the tech coordinator will convene and discuss a realistic timing for the case based on how the other cases in the lab are going that information is then passed on to

the patient if a case is delayed for 60 minutes or more interns read on the dashboard then a physician or physician assistant comes out to speak to the patient apologize for the delay over some insight into what's going on and

promise to keep them updated as the cases go on the dashboard is displayed prominently throughout our Center on several flat-panel screens that we've put out throughout the prep area the floor coordinator station and in the IR

intake center we did this as an effort to keep everyone no matter where they are in the lab updated to the case status for the day as well as to foster a culture of delay awareness a daily report for our delay dashboard is

emailed out to our staff each day in order to encourage discussion and troubleshooting for certain issues as well as to congratulate teams that were able to keep their delays down the previously mentioned color coding makes

it really easy to just add a glance and second see how the workflow went for that day and perhaps one of the most important reasons for using the delays dashboard is that it enables our technologists and staff to log reasons

for the case delays you can see an example list up here this information files back to our database and let's just collect and analyze the delay reasons across the lab the delay dashboard also allows us to get a quick

glance at trends either through the last day or two or across several months in order to try and evaluate further areas for improvement we can submit custom queries to our database if we're interested in interrogating a specific

aspect of what might be causing delays so real briefly I'll just talk about the underlying technology behind the dashboard and so basically it starts out by obtaining the information from our EMR those reports are then processed and

ingested into a custom database information from that database is used to not only help us run custom but also to filter through to the web dashboard that has displayed prominently throughout the lab and so now I'm going

to pass this over to Monique who is going to talk about some of the interventions that we did hi good

now let's look at non-invasive ventilation and I know about like five

percent of the patient population that you are seeing is on some form of non-invasive whether they're on by level ventilation or continuous positive airway pressures right so see if HAP using to stent the Airways open and

maintain a pro a Peyton airway and improving oxygenation but BiPAP and patients that need co2 elimination right need help with the by level support so there's a lot of questions that come up when we give

these talks I'm like how does capnography work effectively with these different technologies of non-invasive ventilation and especially because more and more of our patients are requiring these so we're gonna look at some of the

comparisons of co2 capnography data from three different sample sites and remember I showed you that picture so that picture I showed you with the patient wearing the sampling line with a nasal oral scoop and then there was the

mask sampling port and then there was the port on the ventilator circuit distally so that's what we're looking at here so the diamonds that go I wish I had a pointer I don't have a laser pointer I'm sorry but across the top the

diamonds represent our end tidal capnography values from one liter all the way up to eight liters so as the props are as the pressures go up for CPAP they were monitoring leak rates and what they found is the cat nog rafi

values across all of those were pretty accurate when we're monitoring right here the squares and the diamonds represent the mask sampling port and the the ventilator in the circuit distal to the mask and as you could see that

quality of our monitoring goes down as we progress okay to use yes but just know the limitations of your equipment right and again this is the same thing for our BiPAP Dave data are by level ventilation we're seeing again

across the top if we're sampling right at the airway we have pretty consistent readings but then they start to fall off and we look at the other devices that are further down the downstream what we're seeing here is our end tidal

measurements again with CPAP data and what we're looking at is the patient leak so there's always leaks right when we have these devices on and that's a question well sue if I have a leak how accurate am i okay so now the red is our

nasal oral scoop and if you look at the red graph all the way across depending on the leak rate pretty consistent values right the charcoal color is the mask sampling port and that's pretty consistent probably until about like 10

right until our patient like leak rate 10 liters per minute coming out of that mast and then that value starts to fall off and even more so even further distal down our circuit when we're sampling from the circuit at the past the mask

that's the cream color pretty accurate when there's a minimal leak but as the leak goes up that falls off pretty significantly and the same holds true for our by level ventilation pretty similar distribution here with the

patient leak and the sampling so when we're using non-invasive ventilation yes it's accurate and yes it's accurate we're using high flows and yes it's accurate if we have a huge leak only if we're sampling right where the patient

is exhaling so now I hope that clears that up with the patients that are getting supplemental pressure support with your sampling and you know in those just whatever it can sample from the mouth and the nose right at the source

of exhalation has proven to be the most reliable out of all of the different sampling devices so third evaluate your

conversation about okay I am nearly at a time of 3 minutes compassion so I'm going to just summarize this basically

we've a whole focus on AI and how radiology is screwed and you know I don't believe that we still need to be compassionate to our patients there is a small group of people at Geoffrey Hinton and others who feel that I can be

replaced by an algorithm these are probabilistic algorithms that mathematically calculate the probability of something being X or Y if I was a diagnostic radiologist I would be worried yeah I think they've got a real

problem but those of us who do procedures who look after patients who know our patients name who hold their hand feel their pulse we will be okay we just have to manage the other aspects of what we do compassion is a basic human

need like Maslow's hierarchy of needs like water like air like food and we sometimes I think underestimate this I was very sick over the last four years and my son had a massive scoliosis repair and was quite unwell that a cord

injuries recovered but we learned during this that that most health care is delivered by the lowest paid people in the hospital the patient support worker and they've they're often first-generation Americans

first-generation Canadians they got you out of bed they wash you they change your gown they change your pillow they change your sheets they feed you and we don't pay them enough we don't look after the mo enough we don't educate

them enough we don't give them opportunities enough but this is what I learned from this this experience the other thing I learned is that this racial variation in how people wait if you're in the waiting area of a surgical

or you know there'll be one Caucasian son there will be like you know one Norwegian there'll be maybe five Hispanic or Portuguese people and that'll be like seven Indian families and they'll have food with them and

there's nowhere for them to reheat their food so we're still building our hospitals on a Caucasian model of health care that doesn't work certainly doesn't work in Canada I learned that there's some beautiful things

you know I saw vein physicians come out and talk to patients you are so lucky my gifted hands looked after your loved one you know and then we saw beautiful things this young neurosurgeon really remarkable I was very impressed so the

focus should be on the patient and the family and their major life event not the team not the operator certainly not the operator we are just tools that reassembles the 35 millimeter reel of that person's life and reattaches it and

keeps a plane this AI stuff medicine is not the science of healing but the art of wooing nature I don't have much faith in the ability of Amazon or Google or Microsoft or Facebook to be any more empathetic and compassionate to us if

they're delivering our health care then the way they manage us as potential consumers and I worry about their involvement in healthcare I'm going to skip all this physicians interesting you study art or more empathetic but most of

medicine still boils down to this you sit beside the patient you hold their hand you feel their pulse and you talk to them and you make eye contact and that's what you do and that's why I have such respect for what you do I'm out of

time so I'll stop now and I just wanted to thank you very very much for this [Applause]

program is the stuff requirements and

stuff education all personnel who works in this department the radiology department have to complete successfully the web-based training for level 1 and level 2 safety MRI training including the housekeeping

and also the hospital staff that comes to the department have to fill up a screening form after doing so you'll be given a sticker placed in the back of your ID and it's good for a year and that serves as your pass coming to MRI

so you don't need to fill it up every time you come in and the initial radiation safety training is given by our safety radiation safety officer in the start all it's on higher and also the best training for RT Sundarbans

course training to nuclear med and the pet department it is important if you work in the radial pharmaceutical area that you know the basic concept of spill management the acronym cares I would like to acknowledge that this acronym is

done or formulated by our nurse leader le carré leer C stands for contains pill and opened the checklist the checklist should be available or posted to all areas where major pharmaceutical agents are administered a s alert the

technologist and supervisor they're very knowledgeable in taking care of the spills our is to restrict the area don't let anyone come in and step onto his areas of spill remove the patient if possible he is to educate the patient

you have to reassure the patient there is no health hazard or nuclear hazard to them yes is to sanitize sanitize the area of spill and record in the medical record is very important but what to do when this bill occurs in the zone for of

the MRI we were prior to going that I would like to show you the how our Rachel active spill checklist looks like this is formulated by Pierre Robson it would take you I would give you guidelines on how to do step by steps in

case of nuclear spill and what to do for spills that occur in MRI so on for first cover the area with absorbable material remove patient from stone for prior to proceeding to the decontamination process contact

radiology leadership they're the one to direct surface contamination within zone four and remember the Geiger counters are MRI unsafe so how we check the Geiger counts you have to use an absorbable material you keep wiping and

then bring it out and measure the Geiger level until you keep doing that until it gets cleared also remember that the MRI magnet is always on so have someone is done guard outside the door so anyone that would need to go inside the room

would have to be scanned again and screen this is our ms KCC clinical

interested okay let's look at the

literature so when we look at the AAA say they were the ones that you know they look at a lot of sedation claims and the close claims are what they look at the causative factors of adverse incidents and when they look at sedation

claims that occurred outside the o.r it's sometimes it's been referred to as the wild wild west of anesthesia yeah when you're outside the o.r environment and you're in remote locations the incidence of things going really wrong

increases significantly and I'm sure you guys are no stranger to that right but in remote locations a lot of the claims were judges being preventable thirty-two percent of the time versus eight percent of the times

that that happens in the operating room 62 percent of claims with over sedation as their cause could have been prevented by better monitoring and these are anesthesia providers that are looking at this right and we're seeing the

anesthesia providers have been using capnography and other advanced monitoring as their standard of care for a very long time certainly sedation and claims in monitored anesthesia care these are you

know cases where we're not into baiting the patient very common 21 percent in the specific claims related to Mac anesthesia and again the common denominator here was lack of monitoring or better monitoring could have improved

outcomes so when we look at the professional associations we have UAS a we have the European Society of anesthesiology the Society of gastroenterology nurses and then certainly your organization right the

association of radiology and imaging nursing and what your statement is with capnography it's a RN endorses the routine use of capnography for all patients who receive moderate sedation and analgesia during procedures in your

imaging environments right and and there's certainly there's their statements from many organizations that are all along these lines one of the questions I often get is - well how come we have these recommendations we have

these you know endorsements and such but we're not you know mandated to use it and a lot of that is political there's a lot of pushback from organizations that are gonna come out and say you must use this you know or else they could

strongly recommend things in the anesthesia world it is one of those things that but it's been a long time and I think in time you're gonna see the movement become more strong as far as recommendations go but for now that's

where a lot of the claims are strongly encouraged strongly recommend and such but that means that we should be doing it because the evidence is proven that that it is safer for patients so let's look back at our case study so later in

the procedure our patient develops the following pattern on the monitor you stimulate the patient and position the airway and you have no response what should your next step be nothing because the pulse oximetry is

normal hold additional sedation meds until breathing normalized supplement breathing with a BVM if if required to maintain acceptable and tidal co2 give a reversal agent or intubate the patient well the correct answer would be

to hold additional meds monitor the breathing and supplement the breathing with a BVM see if you can increase the ventilation to maintain acceptable levels well now we're further deteriorating so our same Jane Doe

patient is does not respond to your previous efforts and the end tidal co2 continues to rise followed by a sharp drop in our spo2 concentration despite being on oxygen then the following waveform appears what do we do nothing

decrease our oxygen give a reversal agent or intubate okay I heard some C's what do we want to immediately do she's kind of acutely dropping so yes C would've been correct maybe a slight ago you know before she's really started to

desaturate and certainly that would be correcting the problem but immediately before she decreases her SATs any further becomes any further hypoxic recommendation is to establish an airway

so my name's Heather I'm a nurse in interventional radiology at NYU Langone health in New York and I am the clinical resources for our department so what that means is I'm responsible for individualizing our education to meet the needs of our department and one of

the first things I wanted to look at when I took on the role was our procedural sedation practices and how we can improve by enhancing our knowledge this presentation includes many of the lessons and concepts that I learned

along the way that I think are really important to understanding how to effectively administer procedural sedation so our learning objectives are going to be a review of the guidelines pre-procedure assessment components

including airway assessment pharmacology of the medications that we give and intra procedure assessment so this is the 2018 AAS a practice guidelines for a procedural sedation by non anesthesiologist has everyone seen this

good great as so this is especially important because as you'll see the American College of Radiology and Society of interventional radiology were involved in its development so this is our guideline and I think it's really

important to look at this look at the practice recommendations and see how they align with your own practice and if there may be some changes you need to make first thing you always want to look at when you're reviewing any sort of

literature whether it's evidence-based guidelines or maybe just a review article is you want to look at the methodology that the author used to create the guideline so anybody know why that's important you just shout it out

so if I want to write a guideline for procedural sedation I could find a bunch of studies or review articles that fit my point of view and use them throw them at the bottom and that would be that but even if I use for an demise control

trials which are considered the gold standard of experimental research those randomized controlled trials could be poorly constructed randomized controlled trials so they may have introduced bias at some point into the study

that's skewed the outcome and the findings so you really want to make sure that the authors of the guideline that you're looking at appraise the research that they're using to support their recommendations and that's what the

aasa' task force did so they used randomized control trials and observational studies and then they categorize the strength and the quality of the study findings so as you're going through you'll see that statistically

significant was deemed a p-value of less than 0.01 and outcomes were designated as either beneficial harmful or equivocal equivocal meaning this findings were not significant one way or the other and then they also used

opinion based evidence from experts so they surveyed members of their task force and they did take into account some informal opinion from message boards and letters to the editor so I think a good example here is one of

their recommendations about capnography so they did a meta-analysis of randomized control trials that indicated that the use of continuous and title carbon dioxide monitoring was associated with a reduced frequency of hypoxemic

events when compared to monitoring without capnography and then you'll see at the end of the recommendations this category so for this particular recommendation they labeled it as category a1 - B evidence and what that's

telling you as category a means it was a randomized control trial which is great it was a level one meaning it's a high level of strength and quality and B is telling you that there was statistically significant findings that demonstrated

benefit to the patient now another recommendation that you may see as you're reading through would be the NPO guidelines so if you look at any of the literature about NPO recommendations it's really all expert

opinion because all of the evidence has shown equivocal findings so for example one of the studies they looked at compared the outcomes of patients who had clear liquids one hour prior to the procedure versus two hours and they

found no change in the outcome I think it's important when you're a provider and you're looking at that because you're gonna base your judgment calls on the evidence so you may have a patient come in who had tea up until one hour

prior to their procedure and you have to make a decision whether or not you want to cancel or proceed and you could look at the findings of the literature that shows that there really hasn't been a proven difference in outcomes so you may

decide to just do the procedure versus capnography there's very strong evidence showing it's beneficial to the patient always so I think this is a real big take-home point of why we do everything we do about procedural sedation all of

our assessments and enhancing our practice as a sedation is a continuum and practitioners intending to produce a given level of sedation should be able to rescue the patients whose level of sedation becomes deeper than initially

intended pre-procedure our assessment

about you rolled out the radiant in 2015 and all of this data is great but it's reliant on the nurses documenting it in

all their different areas so how did you did you actually when you built this dashboard did you leave blanks because you just didn't have the data available or did you circle back around and hold the nurses accountable how did you do

that trying to motivate them and engage them rather than it looking like a disciplinary action because you're showing that they're not documenting appropriately yes and that's part of our journey from 2013 we started all these

projects it became evident that document documentation was important when it came to the data and so we actually started training from our technologists and and then to our nurses we created standard work for how they documented time stamps

I'm at different points in the process we audit we audited that for a while to make sure that they were compliant with that documentation so so we embarked on a lot of projects and I did a to greenbelt projects I did one in

interventional radiology and I did one on beginning complete because you really have to start at the ground and if people's reporting is not good you have to fix it so we have a definition for beginning complete for our

technologists which cleaned their data up then we did a project with Jeannie's nurses around and Tommy did some auditing around the time stamps in their system and that took a long time so yes you have to clean your data up first

and that takes projects in order and we also did Tommy led all of us to look at our data and a data validate sort of like Gilbert's thing you know so is it really valid and so we did a lot of work around that as well

the nurses do with themselves and the nursing supervisor did it as well to make sure and the technologists help you with that because what we found is when we handed the data to the nurses and we had them do their audits it was more

impactful than when we did it how would you say your start times improved from pre project pre dashboard to current how did you measure that was the time yes so that was actually interesting especially in interventional radiology because it

it when we started rolling off the Huddle's and the dashboards we had some participation in the with the technologists and the nurses and the providers doing their Huddle's and looking at the information and then

there was a period of time when they stopped doing that and they actually and they actually saw a drop in there on time starts so when we started up they were around maybe 40% on-time start and then when they consistently did their

Huddle's and looked at the - would I use the information they quickly jumped to 60 65 percent so and when they stopped dropped again so it was sort of it proved that that the tools actually worked and now they're actually going

back and owning the work of their own to continue T their Huddle's and use the dashboards in real time yeah rome wasn't built in a day and would you say that this is significantly impacted employee engagement yes I will definitely say it

has previously we had a real sort of segmented nursing work you know silo's and now we have like this cohesive team of nursing and and physicians and technologists working together in IR I will say also part of

our leadership team crisp as part of this as well our senior leaders we did a job we did a change in sort of our leadership structure so before it was like the physicians they led their physicians the technologists led their

technician technologists and the nurses led theirs well we in got a team together so we have a nurse manager the chair of interventional radiology the nursing supervisor and the nursing technologist

and supervisor and we lead as a team now and so we look at volumes together we look at budgets together we look at staffing together so it's not no longer just leading in silos so with that consistency in that that that sort of

got them all together and then so then they see that you can't hit a technologist against a nurse in a physician against a nurse or a technologist because we're all one team and that was a big part of helping this

out yeah sorry before that I was just going to talk about how important leadership was in this so Chris is our operations manager and I would say she made all of this perseverance tommy's the brains I'm the Brawn so I

would like to ask you give more details on the culture like what you were just describing about becoming a multidisciplinary team sure um that's a good vision but practically how did you accomplish so the culture was really

really hard and my Greenbelt project that I did back in 2013 was not successful because of the culture and what we learned was that we had to do something about the culture Jeannie alluded to the fact that our our

department chair dr. chair Toth and our administrative director Karen Buttrey talked to me about this and and they decided it was important that they had leadership teams in each modality so every modality and radiology has a

leader it is the division director the technologists lead and if there's a nurse a nursing lead they meet once a month tommy's does the score cards for them they bring their score cards they bring their a3 reports on

their strategic plan and they sit as a group I sit with them as well and we talk about how they're aligning their strategy to their work what the culture is like and do we need help sometimes we bring HR in if we think we need help

and geney's done a lot of leadership training with the nurses she's very good at it we have Conaty so we've partnered with Dartmouth and we send different teams to Conaty to learn leadership training this

has been really this all started really in 2013 and it continues today and we work just as hard on it as we did in 2013 Neverending yeah and I was part of that Conaty training and it was phenomenal so

it was two of the IR physicians myself the business manager and another radiology technologist supervisor and so really we had to work on a project together and it really brought us together to understand each other's work

and for um I feel like probably the strongest you know asset I have is relationships and and making those connections and nursing wasn't my first career I did practice management and so I worked for a doctor's office and I

kind of know that you have to sort of make sure that everyone understands that we're all trying to get we're all trying to take care of the patient and we all have different responsibilities to do so and there's a crossover if we fight

against each other then nothing's going to work and so that was where I I feel like I probably did the best these again you know brains and brawn and I was just sort of like let's make it all work together people with it so

was that something that you had to work into the amount of hours that it takes to maintain the new task that was being asked for yes so the documentation is part of their work to take care of the patient so for a technologist for

example when they go get the patient from the waiting room they start the beginning the exam in Radian those are things they need to do - as part of the EMR to actually accomplish their work so that was by design already part of their

workflow we just had to make sure that they were all doing it at the same point in time so for example before we standardized the definitions we would have some technologists who would begin the exam when they went to go again the

patient some will do it after they had set up the rooms so we have to standardize all of it so the data was measuring at the same points and for the nurses as well as part of their documentation as they work up the

patient so it's all part of the flow the other thing we do that I want to mention quickly because we're out of time is rounding so rounding is really important so I am the operations manager I probably around three times a day in

every modality and as an example I was just in mr and I saw a red button on their dashboard and I said why aren't we 19 minutes behind and somebody had forgot to complete the exam and everybody was there and they were

talking to me about it and they said yep and they ran back and they you know so I stay engaged the supervisors Jeanne I have two other supervisors tomy rounds you have to keep the conversation going you can't just build these and think

they're gonna take care of themselves because they're not you have to really do that disciplined rounding work so thank you everyone very much yeah thank you and just some related articles that

other other institutions have used for healthcare dashboards I found really really great so I don't know if this is true but I think they're going to send the slides after yeah conference oh yeah yeah afterwards we're happy to stay here

thank you

burned out so if you chose not to do the survey you can certainly go through this and see how many

you can say yes on so are you constantly sick and tired do you ever find yourself struggling to keep your eyes open even when you're out with friends or is it getting harder to get out of bed than it used to be physical exhaustion is one of

the earliest warning signs of burnout but don't we all attribute it to the stressful day that we just had that we're busy with the kids we're taking them to soccer we're taking them here I don't have children but I have very sick

elderly parents so for me it's the other way but when I was feeling exhausted I just I'm just tired it's busy it's busy but it can truly be one of the first signs that you're getting past stress and into burnout so burner can also

cause physical symptoms including headaches insomnia stomach upset weight loss or gain and it can make you more susceptible to illness do you have those people in your department that are always flippin sick do you wonder if

maybe they're burned-out and that's why they're always sick it's a really good question I was talking to the people I currently work with and even though I happen to work at a phenomenal organization right now and it's the best

job I've ever had it's still stressful I was shocked out of the 12 of us seven of them said they suffered from insomnia seven I think that's higher than usual so we had that conversation of you may be starting to burnout you may need to

help you know pull back a little bit so it definitely is an issue so if you're constantly sick or tired and I'm not making a joke on that one even though I could please seek out medical attention to find out if there is a medical reason

maybe your hypothyroid your vitamin D is low because surprisingly most of us are there may be a medical reason that you're always exhausted but if you've ruled that out it may be that you're going past stress into burnout warning

sign number two and I love this one because I can come up with every single day where I feel just a little underappreciated but this is warning sign number two and I love that cartoon is that not adorable

and yes stress can kill you it's easy to feel underappreciated on a given day what we do we do so much stuff all at the same time and most of the time our patients and our supervisors don't even see

what we do let's be honest we do but we're so busy doing it we don't feel all the good that we do if you start to seriously feel underappreciated you need to kind of take stock and why am I so upset

is it me am I having some issues is it I don't have good communication with my supervisor is it an issue with my coworker and maybe I need to sit down with them and work on our relationship it's okay to say no to extra assignments

I know that's a tough one no is the hard word for me those of you that know me yes I am the chair of the Planning Committee I am also one of the master faculty they teaches the review course to study for your certification exam

I'm also the state chapter president I have a hard time saying no I get so passionate about getting involved that I realize I'm under a mountain I learned how to say no ask Pauline we were at a meeting the other night and they asked

someone to step up and do something and my answer was I'm sorry but I have to say no I have to figure out how and when I have enough it's okay to do that you just have to do it professionally and not snarky which as you can tell by my

personality I sometimes have troubles with I did say no I was very proud of myself I waffled a bit but I said no and yes and it's a hard thing to do especially when you want to help okay do you spend your drive home chastising

yourself on how you handled a certain situation I know I sure as heck do so I'm in a couple of slides I'm gonna share with you how I process that information and I'm finding it's being very helpful in moving me down that

burnout scale okay sign number three dreading going into work I just love the guy over on the right I had so much fun with these people okay nobody wants to work on a holiday or a weekend but if your stomach is getting tied up in knots

when you wake up going oh crap I have to go to that job again it's probably a sign that it's more than just stress okay but we don't want you to just soldier through this is your body's Way of

telling you this is not just stress this is abnormal okay now it's gonna happen to all of us some days granted if I had to work that next day or after I worked my 21 hour shift do you think my stomach would have

been in knots getting up absolutely but it shouldn't be consistent okay I loved the third one if an unsupportive nurse manager or co-workers from hell do you have any of those are making your work life a living nightmare it might be

time to look for another job I'm being honest for me that was it that was my solution I was so uncomfortable in the situation I was in feeling like I wasn't getting the support even when I shared with the person that I would realized

how burned out I was I got no support for my well-being and for my marriage it was time to find a new job but it doesn't have to be if you have a supportive group you can come back from it and stay in a job that you love it is

possible okay so if you're not ready to leave the do job try picking up a new skill or taking a class so let's say you always work in IR maybe you go to your boss and say hey can I start picking up a few shifts in CT just to do something

new to challenge myself with a new task it's a great way to refresh that passion for what you do without leaving the job if that makes sense okay our fourth sign does anybody remember what that blow-up guy was from airplane I love Tim so

warning sign number fours you're going through the motions okay so here's my question were you inspired and motivated after nursing school where you went into your shift and you were so excited to go in and take care of that patient and I

can tell you after I got that leadership job I went in everyday all excited on how I could make a difference but do you see that now you're almost trying to avoid the interactions with your patient and you may not and I hope you don't but

there have been times even now as I'm healing that I'm thinking in my head I just wish this patient was shut up please be quiet and then I have the other side you know the devil and the angel

and then the angel goes Lauren take a deep breath it is not your patients fault you're having a bad day you love what you do go back to that take a deep breath and go back but it happens it happens to all of us and it's not that

we're bad people and that we don't care anymore we just we're overstimulated is the best way I can describe it okay all right and our last sign is that you're becoming insensitive to your patients and the the situation I just just

described and it admitted to which I can tell you is an embarrassing thing to have to admit but I admit it you you can absolutely become insensitive to your patients how they're feeling what they're going through this meta port

I've done seven of these today I'm frustrated I want to go home I have a headache I don't feel well but you forget that for this patient this is life-changing probably in the last week their life has been turned upside down

with a million procedures and new diagnoses so it's taking that deep breath and refocusing okay so if you can and that happens take that deep breath try and take a break which I know is hard some of us don't even get lunches

but even if all you do is I've actually turned around and faced the corner and done three deep breaths and my staff because I've shared with them the struggles that I'm going through if they see me facing the corner they just let

me be because they know I just need five seconds to compose myself okay burnout is not a moral failing I struggled with this a lot because I kept thinking like that okay so now we're

morning thank you Andrew hi everybody my name is Monique Dawson and I'm an RN patient care coordinator in the PCC

office here is a list of our team interventions and we implemented many many interventions for this project our team selected what we thought were some of the most important valuable interventions to share with you so what

is a patient care coordinator well the patient care coordinators our nurse known as a PCC that works in the intake Center and this intake Center is a central hub for the I our department I mean it literally sits in the center of

the department we have the prep and PACU on one side with the I our procedure lab on the other the intake Center houses nurses schedulers and insurance presearch staff the nurses responsibility is to include which

includes outpatient procedures we manage a variety of triage calls we lead rounds with the physicians in the teams for the next day we also make pre-op phone calls we do a lot of patient teaching and we see patients in the IR consult clinic

several times a week with our attendings and our pas the intake center I would say is fairly unique I call it the one-stop shop which makes it convenient for providers and patients to give you an idea of the intake center workflow

the clinician or provider calls the PCC directly they request an outpatient procedure so say for instance its patient were Marie who needs a single meda port placement for chemotherapy because she has breast cancer so we then

take this information and we confirm that we have a correct order in the system we also complete any clinical screening questions which would include labs any blood thinners

airway issues we're able to decide upfront at the patient needs general anesthesia or sedation we also get calls from the patients directly like my tube fell out or my tube is leaking which I'm sure some of you can relate to when the

nurse finishes the clinical piece we then hand off to the scheduler who verifies the demographics the insurance and does all the non nursing scheduling tasks and one of the things we really love about our own insurance presearch

staff is that they are experts in explaining indications for procedures to the insurance companies which then helps get things approved and on a short notice so so some of the improvements that we did and implemented in the

intake center just to mention a few was the pregame Huddle's so it's a PCC and the text would get together every week and talk through the next week schedule as indicated that's myself and one of the techs named John going through the

weekly schedule we look at case length equipments and resources that are needed and this helped us learn from each other and to schedule more effectively the other super exciting thing that we implemented was to stop using requiring

tons of labs unnecessary labs for the pre-op labs and to introduce and to tell you more about that I like to bring up dr. hardy Singh who's going to elaborate on our lab reduction initiative thank you

clicker okay hi so first I'm gonna do a

MRA safety is one of our top priorities in our unit we have set up MRI zones zone one being the patient waiting area

zone two is where they change and they get screened zone three is where our control room is and anyone who passes by zone three has to get screened our pet MRI injection room is actually inside zone three and zone four is an MRI

scanner itself we assess risk in our patients for their implants we were iterate to them the importance of bringing their implant card with them just so it's easier for us to assess the compatibility of their their implants

with MRI right now we have the capability of scanning cardiac pacemakers and defibrillators it just needs more coordination with our in-house cardiology service and the implant representative rest assure

expanders and aneurysm clips are so contraindicated inside the skin we tell our patients to remove some items that they are able to remove such as dentures hearing aids piercings and prosthetics if they have it as for radiation safety

we observed the concept of Alera or as low as reasonably achievable you know before we inject the patient with the isotope we keep them comfortable we give them blankets we give them the pillows and we tell them

after they get injected that they are radioactive so we try to limit our exposure to them after they get the injection now we try to keep our distance from them and we have shielding lead shielding within the pet MRI area

now we have lead shield syringes available for the nurses use and we have dedicated a hot hot bath room a hot room and radio pharmacy we Ritter we give these puppies this injection card to the patient after they get the scan and we

were either a to them the importance of this card we have the stories from our patients where after the after they scan gone home and they passed through the tunnels or the bridges that they actually have been pulled over by the

police because the police have very sensitive radioactive detectors there was one patient who may have forgotten his card may have lost his card and he got pulled over and the police had to call our institution to confirm that he

really did have an isotope injected we

little survey to for everyone here does which groups do pre-procedure labs on everybody yeah okay so that's important right because that's one of the things that we really took a good look at to

see how we could improve throughput and improve patient satisfaction so Hopkins has a institution-wide initiative where they really want to look at how we can improve the patient experience and part of that is to reduce

unnecessary lab work we have patients that can come from a distance and that can really affect their interface with us over their experience so there's a choosing wisely initiative that allows practices to look at how they operate

and where they think they need to get labs versus where they may not be necessary labs that are drawn on the day of the procedure can cause delays as we wait for results if we have to send patients to a outpatient lab somewhere

that can also cause a significant inconvenience for them for getting labs that may not necessarily be needed so the Society of interventional radiology has a guideline that was first written in 2009 and updated in about 2012 where

they go through what they consider to be different types of procedures guidelines are always very good but guidelines are just that they're just guidelines and I think every practice should be critically evaluating what they're doing

and who they seem to have procedural issues with related to their to their labs so they break it down into low bleeding risk moderate bleeding risk and significant bleeding risk and you notice that the significant bleeding risk

procedures include any type of procedure where we're making a new hole in somebody for some reason whether it's into the kidney or the biliary system or into the arterial system particularly I would have to tell

you that there are lots of societies that are reeling the use of pre procedure labs just an example here from the Journal of neurosurgery this was actually published in 2012 they looked

s and one drawing their pre procedure labs they found that they had not a very good sensitivity and specificity and because of that if you looked at it critically you would save over eighty million dollars annually

with no difference in the bleeding rates during their procedures I will tell you that there actually have been other societies that have published papers since this one that actually are following that lead the most recent one

that I saw was the American Society of gastrointestinal endoscopy you know something probably a little closer to the types of procedures that we're gonna see and obviously neurosurgery is very different from what we see but you have

to look for things that might be more similar and I would suspect that that group has procedures that are more similar to ours particularly in the low risk group and they have stopped looking at their pre procedure labs most of

these papers have repeated over and over that the conversation with the patient and looking at what their pathway to your door has been as as important as the procedure itself okay with that I'd like to stop and I'll and invite Kerry

to come up and talk about improvements thank you

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

questions comments and accusations please hello this topic is very personal to me I've had it actually had a UFE so this is like one of my big things I work in the outpatient center as well as a

hospital where we perform you Effy's and frequently the radiologist will have me go in and talk to the patient it's from a personal perspective one of the issues which it may just have been from my situation was pain control post UFE

whether you normally tell your patients about pain control after the UFE someone say we are all struggling with this yeah oh it's not what's your question is going to be okay good I'm gonna get doctor Dora to answer Shawn the question

is what do you what do we do with this pain issue you know what are you doing for the home there at Emory there you know and a lot of practices we we don't rely on one magic bullet for pain control recently we've been doing

alternate procedures for two adjunctive procedures to help with pain control for example there are nerve blocks that you can do like a superior hypogastric nerve block there's there's Tylenol that can be given intravenously which is seems to

be a little more effective than by mouth there's there's a you know it and a lot of times it's it's a delicate balance right between pain post procedural pain because you can often get the pain well controlled with with narcotics opioid

with a pain pump but the problem is 12 hours later the patients is extremely nauseous and that's what keeps her in the hospital so it's a it's a balance between pain control and nausea you can you can hit the nausea

beforehand using a pain and scopolamine patch that that'll get built up in the system during the procedure and that kind of obviates the nausea issues like I said that the the nerve blocks the the tile and also there are some other

medicines that can can be used adjunctive leaf or for pain control in addition to to the to the opioids so the answer the question is there are multiple there multiple answers to the question there's not one magic bullet so

that helped it did one of the things that I tell the patients is that you know everyone is different and yet some people I've seen patients come out and they have no pain they're like perfect and then some come out and they are

writhing in the bed and they're hurting and they're rolling all around what and I always ask the acid docs are you telling them they could possibly have you know pain after the procedure because some have the expectation that

I'm going to be pain-free and that's not always the case so they have an unrealistic expectation that I'm gonna have the UFE but not have pain what I also tell them is that the pain it's kind of like an investment right and

this is easy for a guy to say that right but but it's it's an investment the worst part the worst pain you should be feeling is the first 12 12 hours or so every day I tell my patient you're gonna be getting better and better and better

with far as the pain as long as you is you follow our little cookbook of medicines that we give you on the way home and I want you to make sure that you fill these prescriptions on the way home or you have someone fill those

prescriptions for you before he or she picked you up in the hospital and lately we have been and I see that you're there as well lots of other little tricks that are out there right and again there are all

little tricks so ensure arterial lidocaine doctor there is near alluded to and if you're on si R Connect you may it may spill over on some of your chat rooms here people have been using like muscle relaxant like flexural or

robertson with some success but just know that we don't have any studies that tell us how that's supposed to do so when i have someone that is like writhing in pain i just use everything so i do it superior hypogastric nerve

vlog and i actually will do some intra-arterial lidocaine although not so much lately i have been using the muscle relaxant but i will warn you that i've had two patients with extreme anticholinergic effects where they are

now not able to pee from that so you know where we're doing that balance act I see that you're there can I take that question here first just so we're we're doing the same thing we're using the multimodal just throwing all these

things at people and we're trying the superior hypogastric blocks but we're collaborating with anesthesia to do that right now do you all do your own blocks or do you collaborate with anesthesia we do our own blocks okay it isn't it is

not that difficult I would tell you that but again it's kind of like you know you got to do if you start feeling better and then you're like we don't really need them we'll just do it on our own okay thank you again yes what's the

acceptable interval between UFE and for IBF oh that's a your question what is the interval between UFE and IVF so if you wanted to get pregnant yeah and can you have a you Fe and then have an IVF like how long would you have to wait

wait and tell you before you can have that the IBF it I guess it really depends on the age of the patient because we know that that the threshold for which patient tend to have that inability to conceive

is around 45 years old so you know it did below the you know below the age of 45 the risk of causing ovarian failure or or the inability to conceive is significantly less it's zero zero to three percent so I would say that you

know you probably want the effects of the fibroid embolization to two to take effect it takes around 12 months for these fibroids to shrink down to their most weight that they're gonna they're going to shrink down the most I wouldn't

say you need to wait 12 months to put our nine vitro fertilization there's no good there's no good literature out there I don't believe that's your next and so I would say just remember that if you came to my practice and you said you

wanted to get pregnant I will be sending you to talk to fertility specialists beforehand we do not perform embolization procedures as a way to become pregnant there's no data to support that but if you saw your

gynecologist and they said let's do this then I'm sure they'll be doing lots of adjunct things to figure out what would be an ideal time then to for you to have IVF and if I dove not having any data to inform me I would ask you to wait a year

and what will be the effect of those hormones that they gave you if for example a patient has existing fibroids what would be the effect of those hormones that IVF doctors prescribed their patients yeah so fibroids actually

can grow during pregnancy so I would say that most of those hormones are pro fertility hormones so I would expect that maybe you can see some of that effect as well yeah alright if you have any other questions you can grab me oh

you're I'm sorry go with it okay yes we we have time I don't want to keep anybody here for that so I have a two-fold question the first one is post-procedure can you use a diclofenac patch or a 12-hour pain

patch that is a an NSAID have you have any experience with that and your next question my second part of the question is there a patient profile or a psychological profile that tips you that the patient is not going to be able to

candidate because of their issues around pain so they're two separate but we have in success sending people home that first day so I'm looking to just make it better I haven't had experience with the Clos

phonetic patch it's in theory it seems ok you know these are all the these are they're all these are non-steroidal anti-inflammatory drugs so there are different potency levels for all of them they you know they range from very low

with with naproxen to to a little bit higher with toradol like that clover neck I think is somewhere in between so we found that at least I found that that q6 our our tour at all it tends to help a lot so with that said I I don't have

much experience with it with the patch in answer to your second question the only thing I can say is there there is a strong correlation between size of fibroids and the the amount of a post procedural pain and post embolization

syndrome so there really you know we often say we don't really care too much about the number of fibroids but the size of the fibroid is is is should be you know you should you should look at that on pre procedural imaging because

if it gets too big it may not be worth it for the patient because they may be in severe pain the more embolic you put into the blood supply's applying the the fibroid the the greater the pain post procedural pain

are there multiple other factors that would contribute to pain but that's that's one aspect you can you can look at post procedurally on imaging okay thank you very much yes ma'am hi what what kind of catheter do you use

to catheterize the fibroid artery when you pass by radio access yeah so over the last three years the companies have been really very good about that so there are a few things that I without endorsing one company or the other that

you need to make sure that the sheath that you're using is one of those radial sheets a company that makes a radio sheath you should not use a femoral sheath for radial access so no cheating where that's concern you may get away

with it once or twice but it will catch up to you and you need a catheter that is long enough to go from the radio to the to the groin so I'm looking for like a 120 or 125 centimeter kind of angled catheter whether it's hydrophilic the

whole way or just a hydrophilic tip or not at all you can you can choose which one in our practice most of us still tend to use a micro catheter through that catheter although if I'm using a for French and good glide calf and it

just flips into like a nice big juicy uterine artery then I may just go ahead and take that and do the embolization if the fellow is not scrubbed in as well so thanks a lot but they make they make many different kinds like that and more

of those are to come all right I'm you can please please please send us any other questions that you have thanks for your time and attention and enjoy the rest of the living

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

patient who did not come from the street so if you've been here for a few years

you've heard me talk about you know some of my friends this is also one of my other friends who has large fibroids but her fibroids were so big and they were not all very vascular and so I sent her to have surgery and she ended up having

a hysterectomy with removal of her cervix because of abnormal pap smears but her ovaries were left in place so our path forward after doing this procedure from 1995 a procedure that is not experimental a procedure that has

had a lot a lot of research done on it more research than most procedures that are done surgically or by interventional radiologists I'd say that it would require a partnership it is true that we can see patients on our own and we can

manage mostly everything but at the end of the day uterine artery embolization is still a palliative procedure because we don't know what causes fibroids to begin with and as long as the uterus is still there there's always a chance that

new fibroids will come back so in your practice and in mind I believe that a path forward is a sustaining program embolization program which is built on a relationship with the gynecologist that yes

I am as aggressive as any other interventionist that is out there but if this were my mom and that is my usual test for things I would say that where we would like to position ourselves is in the business of informing the

patient's as much as possible so that they can make an informed decision and that we're asking our gynecology partners to do the same is that if you're going to have a hysterectomy for a benign disease that you should demand

and we as a society and you as your sisters keeper should be asking for why am I not eligible for an embolization so si R is actually embarking on a major campaign in the next year or so it's called the vision to heal campaign and

it's all around providing education for this disease stage what I like to tell our patients and I'm almost finished here is when I talk to our gynecologist and to techs and nurses as well I said woody woody what should I expect right

that's what they want to know when I send my patient to you what should I expect and I say that what you should expect that Shawn and myself we're gonna tell the patient everything about fibroids we're gonna talk to them about

what the fibroids are the pathophysiology of it the same things I told you we're gonna tell them about the procedures that treat it we tell them about the options to do nothing we talk about all of the risk and the benefits

of the procedures especially of fibroid embolization and we start the workup to see if they're an appropriate candidate when they're an appropriate candidate we communicate with them and their OBGYN and then we schedule them for their

procedure in our practice there are a few of us who send our patients home on the same day and we let our patients know no one is kicking you out of the hospital if you can't go home that day then you'll get to stay but

most of our patients are able to go home that day and then we see our patients back in clinic somewhere between two and four months three months and six months and we own that patient follow-up their visits and after their year we have them

follow back up with their gynecologist and so that we're managing all of these sites and it comes back to that new again may not be so new for some of the people that have been doing clinical IR four years that shift that we own these

patients if you're a nurse in this room these are our patients these questions need to be answered by us in our department we do not believe that these patients should be calling their gynecologist for the answers to that

like what should I be doing right now should I be taking I haven't had a bowel movement and like that is something that we answer we're the ones that are given them the discharge instructions and we set them back up for their follow-up so

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

workflow for pet MRI upon arrival the patient have to fill out questionnaires the MRI screening for contrast and allergy assessment pet screening form

the RT will review MRI screening for after he checked that the patients at MRI safe and no presence of a Mia Ferris fragments or anything he would give the paper to the RN the patient then will be escorted through the change room and

asked to put on robe and non slip shots this is these are the responsibilities of the nurse in our clinical workflow for pet MRI RN to review pet screening form and contrast questionnaire if patient have to receive gadolinium check

kidney function EGFR below 15 you notify the radiologist except for a of s below 30 you notify the radiologist check for allergies if allergic make sure patients is properly pre-medicated

check for Medicaid presence of medication patches and implanted infusion pumps now also you have to check for patient's blood glucose monitoring I have one but I would but I don't go inside the scanner so I'm safe

check for pregnancy status with pediatric patients we have a special process to follow the iron then obtains blood glucose and record if blood glucose is 70 to 199 we proceed with the scan anything above 200 we follow the

glycemic management with PET imaging flow chart and here's how our PET imaging flow chart looks like it looks complicated by its color coded it's three pages but I would like to show you some key points like the administration

of insulin is also based on the level of BMI you see on the arrow says BMI below 25 and there's another flow chart is if it's above 25 after that the patient will be brought back to the pet designated injection room

remember our pet MRI is located in zone three of the MRI area so prior to that the RT would the screen the patient again the patient would pass through the wall-mounted metal detector and nobody could go into song free without escorted

by the IRT or a nurse you have to swipe your ID to open the door mission when the patients in the hot room are in would obtain the height in centimeters and weight in kilos after that the RN now could do IV access once

secured you call the range of pharmacists that you're ready to inject so we wait until and the FDG dose would come up through the pneumatic children this is how our hot lab looks like the pneumatic tube to your left above is the

shower and we have the hoop to prepare for the dose or check for the dose and the wash station and once the those arrives the nurse injecting and the RT is scanning or the RT assisting just always two artists in one machine in our

MRI Department we have four magnets and only one is for MRI PET MRI it's always two artists in each machine so one RT is assisting you and with the patient so once the FDG arrives we do a patient identification using two patient

identifiers we check the label and the dose if it's correct the FDG then will be injected to the patient once injected we tell the patient they have to wait for 40 minutes during this time we instruct them to stay still not stay

still but limit movement and stimulation and inform them that we have a camera inside that room and the nurses in a and the nurses could monitor them in the nurse's station one RT will set up the scanner and computer

and patient will be screen and wondered prior to so on for so you get wandered twice check for ferrous presence patient then will be positioned on the scanner table by the pet mr technologies it takes 15

to 20 minutes for setup you have seen how the patient is position the whole body is covered by the coils and head is covered by another coil as anybody among he works in the institution who requires time out prior to injection raise your

hand please at ms KCC we do this is done by the injecting nurse and the RT is scanning the RT is reading information directly from the monitor not anywhere in the monitor while the nurse is comparing and listening into the using

the documents on hand this is done to ensure the five rights the right patient the right scan the right area your scanning the right contrast those and rate and method of administration as you all know is either given IV push or by

the dynamic or the injector timeout will be done if patient will be receiving gadolinium once the scan is finished IV access will be removed our artists are trying to remove and inject also so they are capable of removing the IV the

radiation card will be handed to the patient and paste after that patient would be assisted to the change room and discharge there is good thing when you change the patient into the robe and the non-skid

sucks because just in case there's a spill you're not sending that patient into the paper outfit they're not gonna be happy at all now I'm gonna bring you

I'm the FDG is have a radio pharmacy located on the second floor no New York State does allow nuclear medicine

technologist and nurses to inject the con the FDG isotope I know in other states one in particular is is New Jersey the the nurses are not allowed to inject isotope and the technologist has to do it also in addition certain

isotopes and certain scans the ducts have to inject the contrast like the the cervical Lin scintigraphy and some so my question has to do with discharge instructions so just like you give them that little card that they keep with

them so they trigger some radiation alarm and a bridge or on a highway do you give them discharge instructions about if there's small children at home that they're not sitting in their lap for extended period what kind of

instructions do you give on discharge after these patients so we when they come in coupled with the screening forms that they fill out we have some instructions attached to it and does that does have

the discharge instructions but we reiterate to them you know if they have small children or babies and pregnant women and just try to keep their distance for the next 12 to 24 hours just to until the really activity has

wear off so the FDG is like two hours almost for the half life FDA FDA has 60 minutes 116 minutes half life and usually by 12 hour by the 12 hour period they're mostly background radiation okay thank you

we had they have a written instruction like it's like a packet that we give into the market that we do to the patient and the patient have accessed to the web portal that they have and they can be the instructions from there

this is correct so betta bar is still investigational for the most part the only way you can build for it is two different scans you build for a pet and you build for our mr so you've got to get approval for both what you are not

going to get reimbursed for is the registration and that's where it gets a little bit challenging because then you need a radiologist who is both certified uncredentialed to read a pet and an mr so right now most institution bill it as

two different procedures so that's why you that's how we get the approvals just a little information on the side I went back to this case study because I forgot to tell you that in order for the PET CT to have as clear image as the pet MRI

the pet portion I mean the city portion and the pet city would have to be done diagnostically and that this would expose the patient to radiation three times that's why they prefer the pet MRI because yeah the reason why we do it if

we do it mostly for for for pediatrics and it's it and it's because of radiation because you know like our my team is saying you you are going to have this patient have constant follow-up so if you can reduce the amount of

radiation they have from a younger age as we all know it work in radiology DNA injuries occur when you're younger then more is more severe than than later our MRI the pet MRI injection they're all lined with lead and our MRI the pet

MRI room is actually lined with lead so we don't really have Needham let aprons we don't know we don't have wear aprons they are allowed to go to other appointments after they are pet MRI usually with the FDG most of the

radiation after the Tessa's finish is gone they're not more than what not more than radioactive than background radiation so they are are safe to be around people yes that's more for precautionary

measures yes no they go straight to the PACU so we our MRI table is detachable we have an area for where we keep our inpatient bay area we have a structured ready for them to go into right after the test and the

anesthesiologist and if they are Pediatrics the pediatric nurse is with them and they go straight to pack you do like probably like probably less than ten a week right now some weeks we are busy we do for how we do that much some

it varies like we'll do three or four but we are trying because the reimbursement that's one of the big issue our institution is actually eaten eating the cost for some of these to provide a patient with less radiation

especially or pediatric population we have one pet MRI machine for the whole institution three at the main campus we have two we have multiple and other regional sites so the yes

no less than 15 GFR except for the EU vist less than 30 then we notified the radiologists eeeh this is harder to so you this is the it's a linear contrast as opposed to the Catalan bettervest which is

macrocyclic so it's easier for the body to get rid of well there yes well they're only they're already getting dialysis so it's really not much of a harm yes we do patients on dialysis but we make sure the dialysis is done within

24 hours after receiving the contrast yes um sometimes you know you just have it to have it we don't require it for all the tests if you have it we have it we check if it's already in the chart we

acknowledge it you know we don't require for outpatient we don't require but in patients we do all right anything okay so Bernie pet/ct the scanning time for pet/ct is about 30 minutes to 45 minutes Patsy pet/ct is about 30 to 45 minutes

with the pet MRI sometimes they they order dedicated pet MRIs so that is a little longer you have to take note that we do a whole body scan whole body scans for even just for a regular MRI is at least an hour so we try to eliminate

just you know having them have to have to or point to different appointments and just one waiting room one waiting time so that cuts down the response for the patient themselves yes we do for adults it's 12 for the

whole body and then for the pet brain it's about 10 if I'm not mistaken and then plus or minus 10% and then the pediatric doses are cultured calculated base of their height and their weight and there are all protocol by a

radiologist because we have a lot of whole-body protocols we have the bone survey actually that's about 30 or 40 minutes and yes that's an hour and then we have longer whole body protocols diseases

specific and sometimes they try to depends on what the patient's diagnosis is we have whole body scans where they have to check the bone marrow and that needs to be from tips of the toes and tips of the fingers and that can be a

challenge especially if the patient is tall because that has to be in sequest sequestered and sequential patient and positioning is also a challenge alright thank you so much thank you thank you so much

[Applause]

is Kelvin Hong I'm the division chief of I are within the John's Hospital has across the health system I'm privileged to say that this represents just a snapshot of the team that we have both an operational side

but we utilize it within the Qi projects that we hold this is really a long-standing project for over almost four years now so I'm very very privileged and I'm very excited to share with you and obviously

I wanted to emphasize how this can be achieved and the concept of team empowerment is so critical most of our interventions and solutions in successors have been on the backs of really removing barriers and along

interventions to flow from front my staff in foreign we we do intervention team storming we really get the best ideas and solutions from by allowing everybody to be empowered and to speak up and to find solutions and that

transparency is critical to the success and not any operations but when you're trying to improve we free to you know point fingers and I think that it's important to recognize that I think it should be not just top-down but really

bottom-up and really the brainstorming comes from the best ideas and now we're standing then to form a bottom up to allow the physician leadership to go and get the resources negotiate and funding and I think we really need to think

outside the box from top and bottom and this was a an idea oops can someone advance this slide this one just logged off and so this is a one of the interventions I was born on really looking at the problems with increasing

delays and pressures over raw and under-resourced and I don't know if you have in your hospital but there's a increasing reliance on IR to do even minor procedures that traditionally was done you know by the bedside there's

sort of growing reluctance on many physicians do you do less and less at the bedside and rely on more complex interventions even notwithstanding we've had some Sentinel events with bad outcomes of patients been having

procedures at the bedside so there was increasing demand by the hospital for us to do more so this downward pressure of doing more procedures obviously contributes tremendous to patient delays and experience and so

we had increasing request by the hospital to do more more and increasing imaging almost didn't make sense to transfer the patient from the bedside the procedure suite increasing costs delays stresses amongst physicians just

as amongst the staff and we really just under-resourced an increasing complexity of patients doing support procedures for them so really in concept this is one of the interventions for us and to handle really to put together actually a

bedside service to do procedures where the patients were and to fund it and so that we can do the right procedure in the right place at the right time for the right patient in the right service and that there should be all housed

within IR and a1 team and safe for all so this was the intervention to really solution after key our analysis looking at transitioning a team to the bedside and not to do procedures at the suite Jim Bain and fun so that was the big

heavy lifting to fund five providers there were physician assistants who do procedures at the bedside themselves transfer only the sickest patients and to be centrally coordinated that we could coordinate all within the House of

IR so that they expeditiously this patient moves from the bedside to the procedure suite all evaluated and inappropriately to be done in the right place and the benefit obviously is tremendous improvement patient care

satisfaction we have a formalized backup so we really just get the patient to the right place and there's no question we've look at their reduce costs less wait time it's obvious if you don't need to do the procedure in the suite you're

doing at their bedside how that impacts length of stay denied days and some of these very hospital Jermaine Qi metrics that are very very important to Hospital workflows and efficient use of time appropriate use of time and not

importantly for skill procedures and avoid harm to the patient reduce signal veins so we actually had this funded and was and then the scope is some minor procedures you know Paris Toros complex IVs and is a major issue in amongst

hospitals as our patients get a lot of care ops unguarded and the foilage started to do less and less I'm sure you've seen some of these trends within your own hospitals we placed actually almost all the access

for dialysis and so the emergent procedures like shy leaves or non tunneled dialysis catheters are done by the base at the bedside by our IR a bedside service seem to mean as time on characters and so prior to formation of

this bedside service we had simple events that related to almost over a million dollars in claims and so this was but the backbone of the business plan to get this funded and since the inception of our team we actually

haven't had another signal vendor surrounding these procedures and notwithstanding there is actually revenue so and not having complications not having payouts for these risk management events as well as the

collection so we do get paid for this and this is important that you get something funded that you show the hospital that you can make this operationalized budget neutral and so we've analyzed this and shown that and

so what is the impact it sounds great to have this at least when they're not doing it in procedure suite for us actually we even looked at a survey distributed to people who consulted us smatterings of a variety of providers

physicians pas and nurse practitioners and looked at multiple departments how we were doing and we analyzed ourselves so we're always constantly not any improving but we analyzing and maintaining and the survey results in

blue and orange these are highly satisfied or strongly agree with all the turnaround times easy-to-access preventing admissions and and so this is a positive patient experience we really have made we shifted the bar some

negative perception of our service because there's delays to now positive perception of what we provide at the bedside in the suite and in truth from a physician here I'm just happy that there's a shift in in positive energy

and experience with us so this is critically and you know I'll be able to do it so you know we're tracking numbers and our volumes are steadily increasing the more more services are turning towards us and realizing that there's a

great way to to provide service at the bedside and where necessary concert and we'll make this session who needs to come to the ir suite is I think a really good way to also trace some of the patient delays doing

procedures at the right side so I'm going to turn you over to waipapa Dubourg who's on our end talk a little bit us about patient surveys good

okay so what were those outpatient

delays once we figured this out so I'm going to be transparent here as we collected data using the app the delay dashboard app that I mentioned we discovered that 28% of our outpatients were delayed more than 60 minutes past

their scheduled start time so this was like oh my gosh unbelievable that was 28 percent of our patients sitting on a stretcher in the prep area delayed more than an hour past their scheduled start time just waiting and waiting so

honestly once we figured this out this was worse than we expected we were really pretty surprised and more determined so we decided to initially tackle patients in the 60 minute delay category it seemed like at 60 minutes

that's when patients are getting extra nervous maybe upset you know they're like it's been over an hour what's going on so we wanted to tackle that group first and we decided that our initial goal would be to reduce those delays by

50% and these are just some snapshots of the methods that we use to collect our data we used the app to calculate the number of minutes each patient was delayed that was our key metric we used secret shopping to obtain some

observation data we used our patient survey responses and the nuit surveys were fabulous by the way and we performed some financial analysis so why do we have all of these delays what are the reasons our team identified numerous

reasons for delays populated on this fishbone diagram we have finna ties them into six major categories and I assume you guys can relate to some of these reasons maybe labs need to be drawn at the last minute or the procedure before

wasn't scheduled for long enough gaps in the schedule creating an efficiency may be pakis getting full and we need to see a doctor before we discharge a patient under scrubbed in and as we discussed previously just a general awareness of

the delays was huge for us so as you can see by this Fishburne full of delay reasons there were many moving parts in our department and we felt that we had a fairly daunting task as we started to

tackle these delays so now I would like to introduce dr. Andrew Dahmer who will share more about our delay dashboard app

there are advantages of this modality one there's less radiation exposure for

the patient we receive about three millisieverts of background radiation every year with one PET scan a patient can get up to eight years worth of background radiation in just one skin the only exposure of radiation a patient

gets in a pet MRI is through the isotope pet MRI has a better disease characterization especially for areas in a Patou biliary region the pelvic areas and the kidneys information and the relationship between lesions and

adjacent tissue is better delineated with the pet MRI so it's easier to see which part is cancerous and which partners normal cells there are varying opinions and research studies are being done to make a determination if pet MRI

is a better modality than pet CTS well PET CT is a lower-cost skin has increased accessibility there are more PET scanners available and more more technologists are trained for this modality PET CT is a shorter skin there

are no contraindications for affairs implants pet CTS are preferred method for imaging the lungs of thoracic nodules and bone structures however with a pet MRI it's good for soft tissue organs such as the brain the muscle

delivered the kidneys the pancreas our GYN pelvic structures such as ovaries the uterus and cervix and also the prostate there are limitations of this skin one it is a much longer skin one whole body pet MRI can last at least

about an hour there are contraindications with certain implants due to the magnetic factor of the of this test and is not preferred for imaging air-filled structures because it can give off artifacts there

are weight limitations for our machine our machine holes can hold up to about 500 pounds of weight it is this our machine as smaller bore compared to the white board MRI the MRI whiteboy is about 70 centimeters in diameter

our pet MRI machine is only 60 centimeters in diameter in this picture the difference of the 10 centimeter difference doesn't seem much however if you put a patient in there and this is one of our coworkers

he is 270 pounds and 6 feet tall and the white board MRI his shoulders fit comfortably well inside it in the sky inside the scanner however in this pet MRI machine he said he did feel a little snug and a little tight inside

but you also have to take an account that we have to put coils on top of our patients that 10 centimeters does make a big difference the coils will help us give the good quality images that we like and I also have to note that we

have to put the head coil or the helmet on top of the patient's head to give good images of the brain the reason why the pet MRI scanner is smaller is because we have to make room for the pet detectors we try to make it bigger the

gradient coil on the radiofrequency coil have to be further away from the center of the magnet and that compromises the quality of our images so which patient

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

good morning I'm Kari prickle and I'm one of the nurses in the prep and patio and I wanted to share with you some of our interventions that have greatly

reduce our delays in the prep and patio the first one being afternoon rounds with the pcc patient care coordinator the ir fellow and a prep nurse we review all the outpatients and kind of come up with a game plan for the next day and

secondly our IR fellows for our first cases are now consenting at 6:45 before they go to morning conference and this ensures that the patients are on the table and ready to roll at 6:00 at 8 o'clock we also worked on registration

timestamps to ensure that the patient arrived time stamp was not forgotten in prep we really rely on this time stamp so this is what was happening the the patient arrived time stamp was not clicked we had no idea that the patient

was actually sitting in the waiting area the floor coordinator would put an in patient in that time split time and in that slot and as you can surmise it was disastrous for the whole flow of the room and it was disastrous for the

patient waiting in the waiting area so we invited a member from the registration staff to join our lean sigma team and I'm happy to report that that no longer happens and because we don't need as many pre-op labs we've

noticed a huge difference with reduction in prep time and also of course the dashboard is a visual and alerting us to patient delays in real-time and then we intervene based on the color changes one of the major barriers to throughput

in the prep and PACU areas was that the ir providers were scrubbed in and they were unavailable when we needed them we were able to reassign an ir physician's assistant to be embedded in prep and PACU on a daily basis and what a

difference this has made some of her roles include using ultrasound guidance for our difficult IV Stix consenting prep and PACU orders as well as pain medication orders central line removals and then she also facilitates throughput

by proactively using the dashboard for our 68 60-minute delays when the patient turns red on the dashboard she investigates through the delay she offers an apology to the patient and then updates the patient with an

estimated time now Jeff is going to tell us more about the floor coordinator role

on our IR department at Hopkins we have 11 procedure rooms all combined we see roughly 350 patients per week that includes everything outpatient

procedures inpatient procedures our bedside service and all of our consultation clinics so what prompted our project well there were two issues patient delays and patient complaints so for patient delays we were not always

starting our outpatient procedures on time we had three put problems we had some bottlenecks in prep and patio and we had patient complaints so patients are understandably not usually happy about being delayed for a long time

so we wanted to make improvements and we knew we needed to quantify the problem how many delays did we have how long were they but we had huge challenges with this that were not easy for this team to figure out so what were these

challenges there were three basic challenges one on I don't know about everyone else's schedule but on our EMR schedule we were not able to see the delays in real-time the patients were on this schedule but it just there was no

real visual or alert when patients were delayed so in the busy environment of the day the fact that mr. Jones is running two hours late could easily fall off our radar secondly we struggled with how we

were going to quantify the delays we knew we wanted automated data we were extremely determined to find a way to get that we knew we didn't want to use paper we have a lot of patience so we ran a report and that's what we often do

right we want some data we go to our EMR system and we run a report however it turned out we couldn't use the report and why was that well the report was wrong so why does this happen well what happens is let's say mr. Jones is

scheduled in room 6 at 10 o'clock room 6 starts running behind so we just sort of drag mr. Jones over into room 8 and say at 12 o'clock so he hit 2 hours too late when we run the report later this is not reflected because the act of dragging

mr. Jones from room 6 to room 8 on our schedule resets or reschedules his time in the EMR so the EMR system thinks that mr. Jones was scheduled for 12 o'clock start all along when in actuality he was 2 hours delayed we'll imagine running a

report with you know a thousand two thousand patients totally wrong so we weren't able to use that so we had to really get inventive third issue return rate for our patient surveys our old surveys were the paper type the type

that the patients needed to mail back to us and we would get maybe one a month I don't know how your returns are but we had very little virtually no patient feedback or any feedback was really mainly verbal incidental feedback from

the patients or maybe if there were severe delays from the patient relations department so this was really a challenge and this team was really determined to figure this out

are there any questions yeah yes that's a really good sure so the question was do you have any rules or guidelines in my institution about how long the procedure can be before you start

talking about anesthesia versus sedation is that right and positioning prone supine we did come up with a guideline with within our department we looked at a little bit of research but honestly was more expert opinion just best

practice and experience I in in general I would say if the procedure is 3 plus hours the patient should know they're going to be on the table not asleep for three plus hours and talk to them about what that means and if they're ok with

that I just think again that comes into setting realistic expectations that's one of the reasons actually that we're very interested in using Dex med otama Dean because that's going to be a better

drug for those longer procedures first was giving functional and versed for four hours it's just not it's not appropriate but you know and some people would say we'll just get an anesthesiologist them but a lot of these

patients are really thick so in our institution anesthesia is just really super regulated and they require all of these clearances for their involvement no matter what they're giving sometimes they'll require all these clearances and

they give exactly what we were going to give so you know it's it's really a juggling act I would say in our department we really just make sure the patient knows what the expectation is and then we'll usually say to the

provider to if if something goes like if anything looks a little concerning during the case we're stopping and they have to be ok with that and they are they really are but that took a lot of work to get everybody on board with that

type of communication yeah we don't know so they I know I think Sloane is anyone here from Sloane no I think Sloane has with dedicated anesthesiologists they work really closely with them and it's easier for

them to get cases scheduled they will give us they will assign us an anesthesiologist for the day but if we don't have any anesthesia cases they get reassigned somewhere in the o.r and it's a different analysis every time it tends

to be the same group some are stricter than others some will have a patient say I really want anesthesia and we can call up the provider and there they say no problem let me do a quick chart review whereas the next day the provider goes

no absolutely not send them for clearances that's a little tricky yeah right so what I showed you is from the american society of anesthesiology i am not affiliated with them at all i just think they bide non anesthesiologist

sedation so i rely heavily on what they say and they recommend waiting till peak effects so i would look at the pharmacokinetics so for versed it's 3 to 5 minutes so i would wait at least 3 minutes before your readmit a stirring I

think a good example with that is when diazepam with the sedative of choice the on the peak effect for diazepam is 1 minute so when midazolam came onto the market there were a lot of adverse outcomes

with patients because providers administering it weren't familiar with the pharmacokinetics and assumed that the peak effect for versed was the same for diazepam so in theory you could give a patient in 5 minutes 5 milligrams of

versed so by the time that fully hits them they could be in a negative 5 on your raft scale so you know just look at those pharmacokinetics look at that peak effect and I would use that to drive your dosing scheme Atlee that's what I

do and I think since we've done that we've seen better meet info cities and better safety outcomes yes okay yeah we don't do that we do one thing with uterine fibroid embolization swear they'll do a superior mesenteric block

but otherwise we don't do any other type of regional blocks but I have read about that I think that's really are the IR providers giving the block okay right I've seen two with uterine fibroid embolization we'll do an epidural in

advance some I think some institutions or some literature exists about that it's interesting it would be interesting if the IR providers could actually give it though I'm not sure if that's kosher in the anesthesia world but they're

certainly qualified to do it they they do already kind of do it really but so I mean that's certainly something interesting and if you have a provider that is comfortable taking that on and their institution I think it's worth

looking at because anything that's sort of I think mixes things up and and provides a different Avenue especially for high-risk patients is worth looking into definitely yes I believe it yeah

mm-hm right so I'll just repeat what she said so just jumping on the talk about blocks so in her institution they the providers to administer blocks and I think you said

coleus estas Tamizh and PTC's and biliary dream placements they'll use that and it will decrease the amount of sedation that's required sedation being versed and fentanyl that's required during the case which like yes like you

said is really great for patients who are already on opioids previously and habit aller ins yes [Music] something right so we again he left same provider though had a patient on Groupon

or Fein and it was our first experience within about a year ago and it was terrible and she did not have realistic expectations going in of how sedated she would be and she was very very unhappy

afterwards so we talked a lot about that and in that guideline I had mentioned that we made about when we involve anesthesia and when we don't there's a caveat about that that says that if a patient is on

methadone or buprenorphine that a discussion needs to take place making them aware that they will probably not feel very sedated but we will try our best and if they're not comfortable with that we reschedule the procedure with

anesthesia but they have to know going into it that they they may not feel completely sedated and we just keep that open and honest communication but we haven't really come up with a scheme of what's best we did actually try with her

we had her come in one day having taken her buprenorphine the day of the procedure and she seemed okay with that and then we tried having her go off of it so that the receptors wouldn't be blocked she was not happy with that

experience so that's really when a person like that probably would do great with propofol but we can't give propofol so you know if the and if the patient tells us no then we just reschedule with the anesthesia

right - hmm right right right you could at least if they're if they're on an opioid uh if they're on people nor Fein then in theory they should respond to the verse said you could go heavier hand it on the

versed just to get them sedated but they will probably still feel pain but it they hopefully won't remember it that's true I you know with the Richmond agitation sedation scale that's not going to fit every patient that's a

really good point I gave a patient seven of versed during an adrenal vein sampling and she was just talking my ear off I got I fed are you okay you know do you need me to give you anything else no no I'm good I'm good and then I wheeled

her out we got her in the recovery area and she goes sit over I said yeah she said wow I don't I don't remember anything the power of her said that that was like a true and music effect I hadn't seen that so strongly in a

patient before but if you if I had done you know I was documenting that she was a zero it looked like I wasn't doing much for her but then I was putting comments you know patient comfortable denying needing any more sedation so

won't fit every patient so it is good to look at that but yeah as far as the buprenorphine I mean it's it's it's tough yeah if they have an addiction specialist I would say talk to them and they might be

able to come up with a scheme that works for them and if there's a lot of pain expected afterwards those patients are gonna have to be on parenteral opioid therapy they'll probably have to stay you know if you're in a hospital they

would have to stay overnight so those are all things you have to consider yeah yes hmm yeah I'm like it so Adam and Alexa are nurse practitioners that we work with and I'm looking at Adam because

this is actually was a very hot topic for us in the last six months so we actually cheat we met with our sedation committee that's run by that in a physiologist who's blocking us from using pres of X and discuss with him

that in the protocol that guides our practice it's said that you did the timeout and then gave sedation but Ari anesthesiologists don't do that right so they intubate the patient and everything and then and they and then the provider

comes in and does the timeout right before the puncture or incision so we talked about to him about how well if we're gonna do the latency to peak effect it's not enough time right so we do now bring the patient in and start

sedation right away our orders are put in in advance I know some by the attending or the Li P so we have a PRN dose and with an a certain number of occurrences and a titrate to a certain Ross scale

yes yeah so and that our anesthesiologist mentions that our providers are present but it's it's a certain use of the language I think it might be like direct observation or immediately available and our providers

are immediately available it's up to your hospital so our profit our providers aren't like down the street on their way in to work with coffee and street clothes and we're sedating they're they're just down the hall maybe

or the way our department looks is we have a control area and it's like the you know the Central Station and you can see all of the rooms so they might be in the Central Station but just haven't gone in to do the time out yet that

being said I always talk to them before I bring the patient in and say what's the goal Rath and I address any concerns that I have and I think people think I'm a little kooky when I do that for every case but it I think it works really well

and I think the providers really like it so we just already start from the Gecko our line of communication I tell them the patient seems really anxious this is my plan what do you think agree disagree yes the procedural if does the procedure

list or the Lak but I've sedated the patient so the patient if you look at what Jayco describes in the universal protocol it's ideal if they can participate in the timeout however not required because then when they do the

timeout they're right there stabbing them with lidocaine so I like to you know I mean I would argue that by starting I would argue about that by starting at the sedation earlier and getting the patient into a comfortable

state you're more safe because you're doing the dosing appropriately according to the a sa yeah correct right right right

okay I think it's important to say though it's not about getting around Joint Commission this is what Joint Commission says you may feel uncomfortable with it and that's okay

but it is what our accrediting body says is okay we're also not intimating the patient and paralyzing them like an Asst the anesthesiologist is now having said that it's not like we walk the patient in and we go oh I think you're mr. Jones

we throw you on the table there is an initial timeout that's done with the nurse and the technologist and the other people in the room shaking his head yes as so the acceptable amount of time after reversal

yes so if it happens if it happens mid procedure you need to it's I believe the language the a sa uses that you have to have a discussion amongst the care team about whether or not you're going to proceed if it happens after the

procedure in the recovery area or it happens mid procedure and you abort then it has to be at least two hours before you discharge that patient or move them back to their unit where they came from because of that recitation effect and

because you can have really adverse effects from sedation like flumazenil can cause serious delirium I had a patient like that one time it was it was awful and it can cause serious cardiac arrhythmia so at least two hours if you

continue with the procedure I would just make sure everyone knows that you have to be really careful with recitation effects and and all of the adverse effects that you'd be looking at yes I think one more question I'm sorry

with hyperkalemia I have come across I want to say it was in perioperative guidelines when I was looking at the labs that we do cuz we do a lot of unnecessary labs in our department you guys might - I feel like we just really

overdo it I believe the perioperative recommendations are to check a serum potassium if the patient has a reason to have hyperkalemia however right if their hyperkalemic and

they develop a cardiac arrhythmia you know could hypoxia also precipitate that cardiac arrhythmia the results from the hyperkalemia maybe I just went in I wouldn't take an ounce

I would I would consider hyperkalemia severe hyperkalemia and unstable patient because that patient could go into a fatal arrhythmia so I would correct that before you bring them into an elective Percy what's often an elective procedure

so if you're doing a fistula gram you know right five point yeah why are we will go up to five point eight we personally will go up to five point eight because a lot of times they're hyperkalemic

because they're fish too less clothes now and we need to open it right so just again it I don't think there's ever going to be any hard and fast data that you see it's all about making sure everyone knows this patient has a serum

potassium of five point eight we're going to be really closely watching the ECG monitoring yeah thank you everyone thank you so much [Applause]

good morning I don't know if this is on oh it is in terms of reducing delays in your department did you have to do any work around realistic scheduling of procedures putting standard procedure times around different procedures or how

to manage when procedures go and you know run long or you have difficulty managing that aspect of the schedule I'm sorry the audio is unclear it's a little fuzzy up here so you scale and we'll repeat it

yes we did a lot a lot of work around scheduling and that's really Monique in there with the intake Center talked in the intake center we are then we actually have the nurses schedule their procedures and then we hand off to the

schedulers to actually put them in but this way the nurse who's doing an intake can actually determine how long the procedure should be so it allows us to have clinical eyes on the length of the procedure so we modified sort of our

basic list of how long procedure should take we roll in 30 minutes of turnaround time and then we add another 30 minutes if it's an anesthesia case now if the case is going to say require a likely intervention and we can tell oh yes

that's gonna need more time than we schedule accordingly we add time so we really worked hard to make sure that we were scheduling accurate case lengths yeah we constantly analyze those case lengths and continuously try to improve

and recognize challenges hello I'm Nikki Jensen I work in a clinical resource mares clinical nurse specialist roll Mayo Clinic Rochester and I'm very curious about two things first thing is routine lab work and read reduction of

unnecessary labs we too have been doing this where we kind of have taken our own clinical practice expertise and compared with us IR guidelines and have reduced drastically our lab work needed have you guys created established guidelines to

help standardize your process or is this a physician to physician now we we do have a list of procedures that require certain labs for certain procedures again we have a nurse performing the intake so if there's a reason we have

sort of some exclusions so end-stage liver disease we are going to get the pt/inr but if it's a routine meta port placement or line placement we're not going to get pre-op labs so we kind of do a quick assessment in advance over

the phone oftentimes and we make a determination as to what's needed if there is any question then we do go to our physicians but yes we have a list of which procedures new labs and we really knocked out most of our PTI in ours and

then my second question is regarding your patient surveys I love those because us too we do not have really great patient satisfaction surveys available for radiology practice how did you find that is it a particular company

that you went through how did you get this yes so and I can give you more details if you'd like to email me but we because I said we had a we have a patient chief patient experience officer at

Johns Hopkins she was able to get us in on the ground floor of this little mini pilot the pilot was so hugely successful that we adopted it across much of Hopkins out patience and also 23 our Admissions

were allowed to use these the main sort of national surveys that need to there's a requirement that the inpatients have to receive those first you're not allowed to supersede with your own but this company actually was just recently

purchased by one of the major major Chris Kane these two doctors just invented this and all of a sudden now everybody really Press Ganey and talk by various thank you guys I don't know how they're rolling it out and whatnot but

hi I'm Marissa from Houston Methodist Hospital in your title did you write that phase two it says I our patient experience and throughput lean Sigma and Phase two is that is this your face too in your title is this our face Christo

and what was your face one phase one was reducing our procedure rim downtime the time between cases and interestingly for phase one we assumed that that would also reduce our patient delays but guess what at the end we found out it had

introduced our patient Dilys we had great success with you know getting our rooms running back-to-back better our patients back-to-back better but we were surprised so as the next steps on our phase one that was what we wanted to

work on patient delays okay and what's the approximate the corresponding cost of your project because it seems like it's an interdisciplinary what do you have a cost for the whole project sorry that makes just a little fuzzy on that

side so we really saved money for our department and our hospital by implementing this we are just all frontline staff we happen to have a radiology resident who knew how to write code so wasn't his day job

but he was really great I'm raining code and we ended up creating this delay dashboard so that's what I would say to everyone like you never know the strengths of the people who you have but to just ask questions

and brainstorm it's amazing what you can come up with so the the only thing that we really like spent money on would be the bedside service but that ended up being so the manpower for the Qi team is all in-house so we didn't necessary

invest specific but the projects that required hospital support was embedding a PA in the recovery area plus the bedside service and that totaled about you know seven eight hundred thousands it's a moving target but again if you

show metrics that validate why that that type of large number is validated and we it's find itself now but but strictly speaking a lot of the other initiatives were in-house in other but the East surveys was something the hospital was

going towards we just happened to tap into that so it's amazing how many resources you can get should you put the effort in but manpower wise the Qi entire team within IR what you see on front Chen this is just part of the

group is all in-house and not funded this is just part of our work thank you ask you about your inpatient who them on a daily basis who treats you in patients in patients so we have fellows and our fellows together with the four

coordinator like Jeff and add on the impatience but the fellows there's a ticket the fellows sort of is responsible for basically working up the impatient getting consents and then handing off and assisting the floor

coordinator or they had a conversation to determine where that we are and when that inpatient needs to so Jeff Jeff coordinates through the fellow and triage these cases and another question I have how do you schedule your

inpatient and outpatient s-- together in one day how do you differentiate the scheduling between inpatient and our patients how do we fit them into them so most of our rooms we schedule with outpatients

starting at the beginning of the day at 8 o'clock we have one room reserved for inpatients and sometimes we have another room reserved for inpatient lines that is a PA room so one or two inpatient rooms

the others are scheduled with outpatients and then as there are gaps in the schedule which we actually try to avoid those gaps now in patients can be popped in or can follow I see thank you I mean it strictly speaking if you or I

are inpatient come through in our consult fellow triage is it first once it's identified we're going to do a procedure then coordinates with our charge nurse or resource nurse plus the floor coordinator and then it's made to

happen so then the the mechanisms of appropriateness Labs prep is all done and consent done before the patient is transported down and then like Alison says we have a space a room dedicated for inpatients and then sometimes we'll

squeeze them in if it's more emergent origin if you don't mind Jeff can you can you just extent you know talk more about your role specifically what how do you communicate to the nurses upstairs when you coordinate the cases to come

down well every morning you know we get a list of known inpatients and then throughout the day the fellows will bring an add-on slips with pertinent labs and what we're doing when I know that I've got let me back up in the

morning will actually call all the units and speak to that patients nurse to say hey this is what we're gonna be doing are they NPO do they have an IV what kind of drips are they on so that way if the patient is not able to get their

procedure you know we can kind of head that off as a day goes on if I know I've got a room opening up in half an hour I'll call the nurse and say hey I'm sending transport up to get this patient this is what they're getting can you

and we'll just make sure that the patients ready so that way when transport gets there that the patient's ready to come down do you communicate these information to the a procedure nurse any sort of information that I get

there we do have the option to put notes in our EMR set the nurse can know that and a lot of times if if I'm able to I will walk down to the room and talk to the nurses and techs and whoever else needs to know that information and say

hey this is what we're doing what to prepare for and give them as much information as I can so they can be ready - got it thank you so much you yes I have some questions regarding the bedside service

that you guys offer how do you I guess I would say dictate or document the procedure where we are we used to have patients that we would go up to the floor and pull a line or change a tube or whatever and then our document

documentation system kind of got rid of that because we had to work around the computer system versus what was best for the patient so how do you document for those so part of the building of the team is critical is how you document and

importantly how you bill we need to make it financially viable so actually every procedure at the bedside we put into the radiology information system the accession numbers created and actually a before

those procedures are performed by physician assistants under the auspices of the attending on call and those are signed off as procedures then build in and so in that way we also document as well as make it billing compliant so

there's many advantages of actually doing that step and making sure that you get paid for what you do and not only that it's in the EMR exactly what happened and after they get I'm assuming you do some PICC lines bedside

chest x-ray after is that how they document this is how you verification some if it's our sign be verified or x-ray yep okay thank you hi I'm Heather from Sarasota Memorial I have two questions for your nurse intake person

and then the scheduler have you found that it's decreased your turnaround time and what is your turnaround time from receiving in order to proceed your time can you hear me so we receive there we have electronic

orders or they're in the EMR but when we do we require a lot of the providers to call us directly that communication piece is a big deal to be able to get all those questions answered and to get the patients scheduled appropriately so

as soon as they're putting in the order there a lot of them are calling us even as they're putting in the order so we I mean we receive lots of phone calls on a daily basis it's about five or six of us in the office at the same time answering

these phone calls so you have more than one nurse then that's fielding those yes yeah and the second thing for the bedside service do you send that PA or a mid-level person with a procedural person to assist in the room or is that

an expectation of the bedside nurse that they assist if needed that's a great question so there is you know some teething problems one of the problems you eliminated is doing procedures at the bedside you know how much do you

incorporate the the floor nurse involved with the case it's definitely become a little bit of a bone contention but we are managing it because the analogy the converse is that would be the internal medicine physician doing the procedure

and the nurse would be assisting anyway and sometimes it's just House staff internal medicine House staff doing it we're just doing it safer quicker so we've had to do a lot of Education with floor based nursing nursing leadership

to make everybody align that quickly turn around so we yeah but I think you raise a great point sometimes its resource at their bedside we right now we have one provider who goes with the ultrasound performs a procedure with

assistance of a clinic or the owners thank you last question please Fernando from Houston VA Medical Center can you hear me I have two questions so first question is do you guys see

schedule the same start time on all your I'd you sweets it can vary a little bit but we mostly start at 8 o'clock we have one day where we start at nine o'clock we sometimes start a room at eight o'clock except one day of the week which

is Thursday we start at 9:00 with education of anaesthesia our front land tech nurse physicians we all have our weekly education process from eight to nine so every day at eight except Thursdays at 9:00 standardized so then

we look at our first starts in that relation but so how many ones do you guys start all at the same time all the rooms and we start at 8 o'clock Oh second question so since the guys insert multiple drains in they are do you guys

primarily manage this drains including discharge instructions when patients are discharged can you apologize most of the time that would be yes there'd be a consult the primary team

would manage the patient's care be you know after the procedure going forward because they're usually managing their care for whatever problem there is for the abscess train or biliary drain now we our patients do pass through a pack

you the patients who are outpatients who are going to be going home or prior to admission oftentimes and the pack you will give basic instructions to ensure that the patient knows what to do with their drain before they go home

same thing with the intake so know as patient care coordinator nurses we're talking to the patient we're making sure that they have what they need or else we will help coordinate to make sure that they're getting what they need they know

what the plan is in patient often times they'll go back to the procedure room but it depends on whether they are have had anesthesia if they're off the sedation protocol they could go to pack you and then to their bed same-day

admission if the that's not ready pack you okay well thank you so much everyone and please feel free to contact us if you have additional and on behalf of Aaron avir I would like

about engagement so thoughts like those

two thoughts have a genealogy like a family 3 and you can trace the genealogy of an idea back to the original inventor and then who they thought and who they thought and you can follow it through tips why 90 peripheral vascular

intervention drug eluting balloons mathematics architecture and this will be the family tree for vertebroplasty but it's interesting to think that this ultimately despite AI boils down to humans telling other humans and helping

other humans to do something and despite the world of our internet we still need to do this this is a great example so this crazy physicist Schrodinger what it can show dangerous cat wrote this pamphlet saying that there was a

relationship between the wave form of physics and human DNA and this is a letter from 1954 from Crick and Watson to him saying we read your pamphlet from 1939 and it influenced us into this into their structure the figuring out the

structure of DNA so ideas have trickle-down effects like the tree falling in the forest or the wing of the butterfly that we underestimate okay now I'm going to talk about something really important I'm worried about the amount

of radiation we get I began this kind of work about six years ago this stuff doesn't happen overnight it's hours and hours of like rotating planets in your head and trying to make them into something that is real and tangible

so radiation shielding most of you probably wear your little badge but maybe not all the time I don't actually know where mine is currently and we've become so inured to the risks radiation that we underestimate the

damage it's doing to us and we don't all have an equal ability to repair radiation damage to our DNA some of us have mutations that prevent us repairing DNA damage we know the names of some of those B or C a B or one and two and

breast cancer ATM mutation there are known mutations that put a small at risk if patients are larger we get more scatter scatter is the main thing that we experience there are papers like this showing that double-stranded DNA breaks

occur in physicians after treating patients and that some physicians get more breaks than others lead is really really important in preventing this table side lead decreases the amount of dose skirts that

we get enormous ly using all the barriers is rare we make compromises we get rid of them the amount of lead that we wear varies from person to person the age of the lead that we wear varies light weight protective garments are a

problem we did some studies in a Mayo Clinic on this and only three out of 19 passed so you're trading off your protection for the weight of your lead led toxicity LED is one of the most toxic agents on the planet

60% of lead aprons have LED on the outside so something I'm gonna work on when I go home is lead levels in my staff this is a funny photograph a bunch of us figuring out that we had no hair on the outside of our left leg

this is radiation injury to us we know from the very beginning of radiology that people radiologists died right they sat in the field they lost fingers they lost nose noses etc and and they did badly so I had all the stuff in my head

and I came home and my mother-in-law who I like don't tell her came home from our Cancer Hospital Princess Margaret with the list of medications not to take prior to her radiation therapy I said Karen why did

they not want me to take these these are all my vitamins and I looked at them they're all antioxidants so I thought okay antioxidants if they prevent DNA damage from huge dose radiation could work for us and for our patients so go

outside to Ronan my son and the dog Cora and we went for a walk and Cora met another dog and that got you know playing together and the guy who owned the other dogs said to me what do you do and I said well actually I'm a doctor

I'm thinking about my research projects what's your research project of the wasana antioxidants to prevent DNA damage from radiation exposure and he said I make antioxidants and so this is like that letter you know this happens

and there's a certain state where it happens more frequently it's a weird thing like I'm a scientist but I believe that so I used his antioxidants and bunch of experiments on myself I drew my blood radiated it then took the

antioxidants may be slightly hypertensive cuz there was a lot of uric acid in it but I felt great and then I found I could decrease the number of DNA breaks I got this is the man Ivan D'Souza

and so I thought this could be good this certainly works I can decrease DNA breaks with antioxidants I went out as visiting professor to Dalhousie they grow a lot of apples out there red Canadian apples so why they make all the

apple pie I like pie and so I told them what I was working on they said we have extract from Apple skins that is a really powerful antioxidant so we added it to our formulation we license three patents I formed a company named after

the dog Cora Cora med and I studied the nature of DNA damage from x-ray exposure basically what happens is x-rays impinge upon water molecules which then break releasing free radicals which then bind to DNA and then

oxygen binds to that break site so you get an oxidative injury to your DNA antioxidants bind the oxygen and the free radicals and prevent that we are

gets pet MRIs right now our main focus are our oncology patients it helps us

determine the type of cancer they have the diagnosis of cancer assess disease progression treatment therapy and treatment planning and some antecessor treatment response so let's say a lesion is FDG avid and

has low blood perfusion that would help our physicians to us to say what kind of treatment they can give to the patient pet MRI is also good for patients who can tolerate longer scans right now it's a very young modality

there's still a lot of research goes on with this and coupled with that is advantage of research right now we actually in the Memorial sloan-kettering we have started using this instead of FDG we've used gallium 68 of to assess

neuroendocrine tumors who have also done cervical lymph Austin Tiger phim where FDG is injected directly at the patient's cervical cavity and that helps map out the lymph nodes in the survey in the pelvic area this can be used by the

surgeon and see what lymph nodes can be sampled during the surgery we provide some education and assessment before during and after the pet MRI we assess for the patient's allergies we tell the patient's they have to be NPO at least

six hours prior to FDG injection as for our anxious patients they often come pre-medicated and this just comes with some care coordination with their physician the physician would prescribe some low-dose anti-anxiety medications

and the patient would take it an hour before their test as for our claustrophobic patients we what we have done is we let them see the Machine we let we let them feel the Machine we put them inside if they would want to and it

would be up to them if they would be tolerating the scan we assess for their diabetes regimen and my refe will speak more about that later we assess for patients pregnancy status on patients loving to fifty years old process for

their breastfeeding status and screen their implants during the pet MRI we tell them about the coil placement we give them an emergency call bell and we tell them to decrease their movement well being is like although our some of

our patients would say I didn't move but then the image so differently there there's a possibility that the magnet can induce some involuntary twitching after the MRI we tell them that they can resume their

diet they can resume their diabetic diabetes regimen and as if they get MRI contrast they can pump and dump for about 24 hours after the test but if they don't get a contrast they can keep their breast milk inside the fridge just

to help to decay just to decay the isotope that was given to the patient it doesn't give any harm to the baby

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