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Summary of Bleeding RIsks | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
Summary of Bleeding RIsks | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
atwellchaptercloselyguidelineshemamedicationsmoderateNonenursespartneringpatientspracticesradiologyriskworkflow
Building the Radiology Nurse Dashboard | Innovation and Application of Real Time Nursing Dashboards
Building the Radiology Nurse Dashboard | Innovation and Application of Real Time Nursing Dashboards
accomplishalignbuildbuiltcapturecategorychaptercovercreatedatadesigneddisplayeddocumentationengagementintentjeannejourneymeasuresmetricsmodalitiesmultipleNonenursenursesnursingpendingproductradiologyrealrelevantselectedstaffingsystemteamunderstandworkflow
What Makes a Procedure Moderate/High Risk? | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
What Makes a Procedure Moderate/High Risk? | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
aspirinbleedingcategorieschapterhematocritliteraturemoderateNoneplateletsproceduresprophylacticradiologistrecommendrecommendedrisk
General Screening Criteria (specific to bleeding risk) | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
General Screening Criteria (specific to bleeding risk) | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
acuityalertanticoagulantanticoagulationbiopsybleedingcardiacchapterchartdysfunctionhematologicalhistoryhypertensivelivermedicationsNonepatientpatientsplavixprocedureprovidersradiologistsriskstablestentthrombocytopenia
Pharmacology- Antagonists & Additional Medications | Procedural Sedation: An Education Review
Pharmacology- Antagonists & Additional Medications | Procedural Sedation: An Education Review
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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
anticoagulantscampuschapterclinicclinicalcoagulationgraduatedguidedguidelineshospitalinpatientinpatientsinterventionallabsmayomedicationsneuroNonenonvascularnursenursingpatientspracticeproceduresradiologistsradiologyrochesterspecialistultrasoundvascular
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
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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
anticoagulationcallschapterclinicaldatabaseguidelineslivermayomedicationNonenursespanelpatientpatientsphysiciansprocedureradiologistradiologistsspecialtytriagevalues
The Dashboard Implementation | Innovation and Application of Real Time Nursing Dashboards
The Dashboard Implementation | Innovation and Application of Real Time Nursing Dashboards
applyappointmentassessingbufferchaptercheckedinterpretlatemetricsminuteminutesmodelNonenursenursesnursingpatientpatientspendingproceduralradiologyscheduledtimetotalutilizationworkup
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
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
biliarybleedingchaptercriticallygastrointestinalguidelinesimproveinterventionallabsneurosurgeryNonepatientprocedureproceduresrisksocieties
Q&A- Respiratory Compromise | Respiratory Compromise: Use of Capnography During Procedural Sedation
Q&A- Respiratory Compromise | Respiratory Compromise: Use of Capnography During Procedural Sedation
adverseanesthesiaanesthesiologistcathchapterguidelinesinstitutionintubatedlistsNonenursenursespatientpatientsprocedurequestionsafetysedationultrasoundversuswaveform
Organizational Strategy | Innovation and Application of Real Time Nursing Dashboards
Organizational Strategy | Innovation and Application of Real Time Nursing Dashboards
alignchapterdailydartmouthdatadevelopfrontleadersmeaningfulmetricsNoneorganizationalorganizationspacemakerspatientsradiologyseniorstaffstrategiesstrategytranslate
Data- The Story Behind the Numbers | Innovation and Application of Real Time Nursing Dashboards
Data- The Story Behind the Numbers | Innovation and Application of Real Time Nursing Dashboards
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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
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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Overview of Respiratory Compromise | Respiratory Compromise: Use of Capnography During Procedural Sedation
Overview of Respiratory Compromise | Respiratory Compromise: Use of Capnography During Procedural Sedation
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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
alertbiopsiescallcallschapterclinicclinicianFellowsguidelinesmayomedicationmedicationsNonepatientpatientsphysicianprocedureproceduresradiologistradiologistsschedulingtriage
Q&A- Risk in All The Right Places | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
Q&A- Risk in All The Right Places | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
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Pharmacology- Opiods | Procedural Sedation: An Education Review
Pharmacology- Opiods | Procedural Sedation: An Education Review
acutechapterdrugelderlyfentanylinactiveinhibitorsintubationmedicationsmetabolitesmetabolizedmilligrammorphinenarcanNonenurseopioidpatientspharmacokineticpotentproteinrenalresidentversed
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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Cath Lab Simulation | Cath Lab Academy: An Adjunct to an Orientation Program Using an Interprofessional Approach
Cath Lab Simulation | Cath Lab Academy: An Adjunct to an Orientation Program Using an Interprofessional Approach
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Combining Guidelines with What You Know | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
Combining Guidelines with What You Know | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
anticoagulationchapterdysfunctionfloraguidelineguidelinesheparinlovenoxmultidisciplinaryNonenursenursespatientpatientsprocedureradiologistrestartedscreeningserviceworkup
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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Practice Guidelines | Procedural Sedation: An Education Review
Practice Guidelines | Procedural Sedation: An Education Review
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Pre-procedure Assessment | Procedural Sedation: An Education Review
Pre-procedure Assessment | Procedural Sedation: An Education Review
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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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What Makes a Procedure Low Risk? | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
What Makes a Procedure Low Risk? | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
biopsiesbleedingchapterdetectableliteratureneckNoneparacentesispatientspracticeprocedureproceduresrisksuperficialthoracentesisultrasoundwarfarin
Transcript

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

so I actually work mostly in

interventional radiology in CT and ultrasound which is actually on a different floor that where we have our cath lab and I our stuff upstairs so that I our doctors are each going between two floors and one of my biggest

concerns is when we're doing moderate sedation the nurses are down in CT and ultrasound it doesn't matter how many comorbidities the patients have the aasa' is always three or less because they want to justify doing it downstairs

with just one nurse and the procedure list and I just and then you have somebody who obviously needs to be having anesthesia involved and now the anesthesiologist or the nurse anesthetist they get a circulating nurse

with them and I'm just wondering is there a cut-off that anesthesiologists or nurse and necess use for saying okay the a SA when it's this you have to consult with an anesthesiologist before you proceed with a nurse just giving

sedation that's a great question and that's institution unfortunately that's one of those things that is like institution dependent policy and procedure politics finances you know sometimes you'll see patients who really

are in a sa three four or four and a half that are made to be an a sa to write you know so they could be done during off-hours without anesthesia unfortunately it's a symptom so the organization's ever sit together and say

let's look at this globally for the patient safety and if we're doing sedation in this scenario we should still have somebody there who's trained to do the backup for that person I can't speak to your organization's policies

because I don't know them I know that they recommend catalog' Rafi I do know that the avenues to look at would be the Joint Commission in the anesthesia patient safety foundation you know for guidelines and again guidelines are just

that they're guidelines they're not mandates especially you know when institutions develop policies procedures protocols and such I do know on the third bullet down is we have a whole implementation project that we've rolled

out so one of the questions in addition to technical questions we get is how do I go to my institution and kind of change practice a little bit and usually the question is like implementing capnography but it it's a three-part

series that we did on how to implement change in an organization who are the stakeholders who are the champions who can you really talk to that would create change and whether it's the chief of anesthesiology is the person who's your

roadblock or your best friend is it the VP in nursing is it the safety committee you know cuz it takes one adverse event one Sentinel event unfortunately sometimes to change culture it takes more than that I know I know we're

trying a little at a time though but think it was a great comment in question was just made in our institution anesthesia kind of hit at this because the nurses were concerned about what she was just saying and so they worked with

the directors of like IR cath lab the medical directors to you say let's come together and figure out you know if it's a four it doesn't mean that every four needs to be you know it can be given sedation can be given by nurses but at

least get an assessment or things like that and in our institution nurses are able to if they feel like they needed anesthesia consult they can do the anesthesia console it doesn't mean they're gonna have anesthesia but

anestis you can tell you what to give and what not to give mm-hmm but that's that's what they're trying to do they have done for cath they're doing it for IR too and that is I forget them term for it but that's a team collaboration

and so and I must said where we work we actually screen the charts ahead of time because we have some really remote places and some not as remote and it's like the litmus test you know somebody with a BMI 55 is not going to be done

down the street they're gonna be done where emergent resuscitation is right upstairs if needed and same thing holds true like in our institution like anybody can call a patient safety stop meaning like I don't

feel comfortable with this let's not go forward and and again the procedure lists are another list of those champions because procedure lists they care about their pain you know they don't want to see adverse outcomes and

they're so focused sometimes on what they're doing that they kind of black you blank out on some of the peripheral factors and no one wants to see something bad happen on their watch so the procedure lists can be

instrumental in getting better monitoring or advocating for advanced levels of care or at least support for the nurses to have there's another question in your experience are the waveforms the same as far as a

ventilated patient versus a non ventilated patients have you seen any discrepancy in the actual performance that waveform itself yes and no okay so so I'm ventilated patients somebody who's really hyper dynamic I mean I've

seen like you could see sometimes their heart beating you know like just some of the little fluctuations or oscillations for the most part no difference if the non-invasive ventilation patient is getting monitored really right where the

gas is being exhaled like right here you may see some other you know and somebody is intubated so if there's secretions you might see like a little you know blip and such but when things are perfectly working the way they should be

working in both the intubated patient or the patient with an artificial airway versus not the waveform should be spot-on but if you're not seeing that is it a COPD or is it somebody who's got you know bronchitis in there yeah if

you're not seeing that full square waveform the question should be why not is my equipment not working good question great questions did the sign-in sheet make its way I know the spiral bound notebook is over

here but please do make sure that you put your name your email address and you'll be emailed because so you could fill out an evaluation and make sure that you get c e for attending this opportunity today I hope you guys

enjoyed it I hope you took something out of it I hope this just wasn't the basics for you today I hope that there was some value added in to coming today please do hang around we'll be here we'll be in the exhibit hall I know that there's

going to be many more events that are have this afternoon but the rest of the team will be here and we really do look yeah I love working with nurses that are providing sedation's I feel like you're the you're my people you know but you're

the people that are doing this day in and day out and you really are that that patient safety advocate and I feel like when I speak to a roomful of people that you guys go out and teach your precept ease and create change that's going to

impact patient safety so thank you for your attention today and thank you for attending [Applause]

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

as Chris described to you we really walked this journey around bridging the data gap from our front lines all the way to our senior leaders and we thought

this was very important because we didn't think we could drive a sustainable organization if everyone was not on the same page or even in the same book so we had to start helping the staff understand the story behind the

numbers and help them understand that every number actually has a story and is connected to their work it's not just random numbers these are things that also define patient care and can help us improve the way that we take care of our

patients and so the scorecards were really key in creating that alignment across the organization because as you can see on this chart here the senior leaders the radiology mid-level leaders and the

frontline staff all review the scorecards so AB monthly staff meetings the radio radiology leaders review the scorecards with the frontline staff and then we have our radiology director and our clinical chair review the scorecards

with the institutional senior leaders as well so all across the organization everyone had the same understanding around performance and if there was a strategy strategic vision that our senior leaders had they could easily see

how we could accomplish that based on the numbers that we had on our scorecard and then when it came to the dashboards these were as Chris mentioned more real-time frontline tools that were applied by our staff and but the metrics

on the dashboards were also included on the scorecards as well so when we designed the dashboard we pulled some metrics from the scorecards and thought about which which of these metrics would be more relevant in real time for our

frontline staff and so that way we restraints where we were continuing to build that competency for our frontline staff to help them to understand how to use data to drive decision-making in real-time and finally when it came to

the strategic plan we still have our senior leaders design strategic plans but our radiology leaders were able to move that strategic plan through our strategy to deployment program to define more specific strategies for radiology

and then roll that down to our frontline staff through their one on one performance management goals so this really helped us to start to create the same level of expectation across the organization as Chris mentioned we might

have senior leaders say well we have our strategic vision of increasing or falling by 10 percent over the next year and for our frontline staff that might be difficult because if they to them their work might be chaotic and they

think they cannot possibly do any more volume but when we presented the scorecard for example on s Chris showed in I arm at a 65 percent utilization everyone could see that if our benchmark was 80 to 85 percent we still had more

capacity in our rooms to be able to service more patients and on the same scorecard we could see our on-time start rate which was actually kind of low around 50% and so that helped us engage in conversation

with our frontline staff to help them understand that our issue was not necessarily a capacity issue we had the capacity to increase volume but the way that we were managing our workflow as you can see from an on-time start was

not great and so this helped them to start to identify projects that they could lead to help to manage their workflow better and with the dashboards they could actually see real-time improvement or real-time changes as they

made decisions around their workflows so again our goal to this journey or our journey to this one box was around bridging the data gap and to really create a sustainable organization where each frontline staff was empowered to

solve problems and have the data that they needed to do that objectively so now Jeanne will go over the current state of our nurses as we embark on that next steps of up - specific dashboards for them thanks to me

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

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

so reviewing the evidence in relation to respiratory depression and airway

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

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

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

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

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

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

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

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

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

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

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

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

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

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

would probably be how do we make our careers sustainable how do we make our lives healthy and well balanced in organizations that may not understand

what we do how do we maintain our humanism in a system that is focused on efficiency we expect a lot from our patients we send them home too soon and not all patients who go home have the environment at home that allows them

recover so they come back because there's no one to get them out of bed there's no one to get them to the bathroom there's no one to change their dressing their PICC line blocks you know simple things so we've gotten to a point

in in the excel file accountant driven behavior of things that we've forgotten that this is the about the art of wooing nature the science or the accountancy of healing and so we as a group need to

advocate for our patients and say no this person can't go home you know so when we look at our careers at our at our lives on a daily basis there are stressors that we all experience so this is one of the big challenges that we

face given what we do there's the risk and stress of what we see in our patients and the things we see the the dreadful things we see and more and more in radiology essentially were an adjunct to the emergency room and we see

terrible things I still remember the things I saw at Hopkins the the young men being embolized to maintain their cardiac output so their family could come in so they could become transplant donors stuff like this that's just

gruesome we get exposed to radiation which is not good for us one day I think radiation will be seen like asbestosis now seen we get exposed to blood and blood from infected patients with types of hepatitis that even that don't have a

member of the alphabet associated with them yet you know we get exposed to resistant Hospital organisms my wonderful dog Tessa who's dumb as a plank you know but lovely animal tore her ACL and I had to go bring it get

repaired and the vet said oh you work in a hospital well there's a 92% chance your dog will have em or sa because the vets know that if people who own the dogs work in hospitals their dogs are colonized with Mrs a in other words

we're bringing it home and our clothing we don't know this we get back injuries more more frequently because patients are getting larger and we have conflict sometimes using techs and nurses sometimes we text nurses doctors our

administrators and we have excessive overtime that's not an option and we often work in areas that are crime ridden so driving in and out is dangerous and we have financial stress so all of

this makes it a challenging life and we have to figure out ways of making this sustainable and happy and remembering why we did it and remembering why this makes a difference burnout is actually a

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

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

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

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

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

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

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

questions a question comment I'm

Canadian I work in a Canadian hospital and I would say my hospital has an excellent just culture this is a practice so the other day we had a bunch of unusual things happen to begin with and I made the first error and it was a

medication error I forgot to order chemotherapy page went into the room they filled out their interventional procedure safety checklist and someone checked off all the equipment I need for this procedure as present checked it off

he did a time out in the room completed it the doctor started the case when he got the catheter in the right place that's when they discovered there was no chemo because I had forgotten to order the chemo that was the first mistake and

so we have an RLS reporting and learning system I filled it out etc and my manager was 100% supportive that art Swiss cheese lined up and you know the three things that should have caught it did not so this the safety procedure

checklist failed and so did the timeout but the ultimate one in my opinion and I wrote this in my report was that the doctor should never have started a case if he didn't know everything was ready and my my or

zatia was extremely supportive of everything I did but that doctor still thinks it's my fault that we didn't do the case and you know I'm not a new grad obviously and I'm you know he's wrong and I don't care

I fully own my mistake but he's wrong in that the whole thing was my fault so sometimes your organization will 100% support you but you might have people that are not in the just culture part and they're just looking to blame you so

you know I feel like I've done my thing I've learned I've set arow and I'm changing the situation and so it's important to remember that part of your just culture and and not focus on the people are trying to say it's your fault

to stop you from reporting in the future not really a question sorry no that's alright that's great because I think that illustrates that anatomy of the error in healthcare with that blunt end of the system and the sharp end so he's

kind of stuck in the sharp end isn't he he's blaming at you thank you very much because errors are made and they're devastating not just for the patients they're devastating to a practitioner so I think we have to look beyond the just

culture and there's something called second victim and you need second victim support and I'm trying yet actually where I work to have a program instituted sort of like a Rapid Response Team when an error is made so that you

can have the support and it goes beyond changing a policy or procedure or doing a root cause analysis but you need emotional and psychological support for the practitioner that made that error and came forth to report that error so

just wondering also how many people have a second Victim Support Service at their institution see there very little I think we have to really look at that and look forward and implement maybe something like that I

agree and we are one of those institutions that have the second victim and and that in itself is kind of a it's a topic but absolutely and and that does go hand in hand with that just culture to support because it is very

devastating when you have that air and depending on the patient safety event that occurs you know if it results in a patient death that really sticks with you and also events that we don't just stop there with ours so we have a

psychologist that's on board that talks with our physicians and then we have a liaison in our Employee Assistance Program that's also psychology based for our staff so that they can have further follow-up but even even if it's a

devastating event where there wasn't anything that was done wrong it's just that we were gonna stop that train that was rolling with this patient you know how devastating sepsis can be you just sometimes aren't going to stop

that train and and the patient is going to pass but the practitioners that were involved in that care are are moved by that most recently we had a three-year-old who passed and they had they were septic had a cleft palate and

they had a abscess that had formed after the surgery so you know that can be very devastating we do we pull our practitioners into that and that from risk management we're able to initiate that so we absolutely ask when a serious

patient safety event occurs or one that we can pick up that there's some a lot of emotion wrapped around it we'll ask them how they're doing and then a we can self-refer a person and then EAP we'll reach out to the staff member and

our psychologist we'll reach out to the physician if we if we really feel that they need just a little helping hand so yeah it's a good program I kudos to you to get that started so much for your talk today I just wanted to reach back

to you and ask you how your organization or other organizations support the exposure of those events within your hospitals I happen to be from Vanderbilt University Medical Center and we have been in the national news recently and

so there's been a lot of conversation with my staff and you know you you pull your team together and you have conversations and and the event occurred in 2017 and I'm facing them in 2018 2019 and they're like how come we don't know

these things happen in our organizations and you know there's a lot to learn from patient error and Sentinel events and I'm just curious to learn from you how how do you expose your nurses within your organization to those very private

things that go through risk management can you share with me sure sure thank you that's a great question so we do out of patient safety and risk management we do Grand Rounds and we do one once a quarter and in that way and

we will on some sensitive issues because some of it can be wrapped up in legal if there's lawsuits pending and stuff so you you really can't share some of that and I think that that might be some of it a little bit of the disconnect that

staff have because they may or may not know the players involved which gets to be a little tricky so so time helps but we we do let them know that the event happened here and that's that's the title of our

Grand Rounds and we bring those patient safety events but will de identify them quite a little bit and change some of that to protect the practitioners involved and also to focus more on the on the patient safety event and again

focus on the system so on the on the blunt end rather than so much on that sharp end because that sharp end it's sharp for a reason and it could hurt so it can hurt our clinicians describe to me who all is involved in your Grand

Rounds and where that takes place so we have we have a couple of different venues in our Hospital depending on how large we anticipate it to be so we actually have a an auditorium that has the auditorium seating because we're an

academic Medical Center so we have that that luxury we also have some smaller venues depending on what's happening so depending on what the event is we may have outside people come in and talk about that in fact we had the one of the

big things that we're working on right now is sorry the burt behavioral emergency response team so and awareness awareness wrapped around that so one of the things that we're actually looking at is bringing in the the nurse who

speaks from the del noir event to come to the hospital and speak about issues she presented very well very strategically and just to kind of heighten that behavioral awareness that we don't want our nurses to be you know

subjected to that so so depending on what's happening we may pull in outside most of the time we will involve people from our own departments throughout the hospital depending on what the event is so we've we've had some we had a wrong

patient that was they had a procedure done not a wrong patient we had the wrong the wrong procedure was done on the right patient and we actually brought in from ultrasound and from I are including the

physician involved with the case and then a risk management person and made up a panel for people to we presented and then fielded questions now that actually went really well we standing-room-only so okay that was good

so that's some of the strategy that we use thank you you're welcome because we have a computerized reporting and learning system our system sends out a monthly report on just the trends so if we're seeing a rise in a certain

thing and sometimes it's just you know Falls so remember to look at your Falls where whatever but sometimes it's more specific so there have been you know a mixup on this drug in this drug and and pharmacy is doing this to try and

alleviate that and so well it's not everything and it's obviously not any that are illegal it does give you a sort of months a month overview of what kinds of things people are doing wrong and the best part about it is these were all

reported independently so you can it's showing us as people that someone listened to our report and that something's being done about it right very good point and that's some of what we hear too is that these systems allow

you to anonymously submit a report which is fine we're interested in the event we want to hear the the event it's helpful when we have a name because if if I as the MIS managers that's looking at this report if I have a question I'd like to

go back to the person who put the report in to kind of find some more information out but it is not necessary and we're like I said we're more interested in the event but we we to send out a report that kind of aggregates our involvement

but it what our top five reports are for the month but we hear a lot of disconnect that our staff don't hear about what's happening what the report is I put that I put that record in and I don't hear anything about it well did

you give us a name so because the manager the unit manager also sees that and that's why we encourage our managers to use some of those reports that they're seeing as a patient safety during their event during their

department meetings get that word out and what they're doing about it because leader leadership so does do some effect some change but staff might not realize it's connected to the event that they turned in I was just curious amongst us

all who when you get new hires or new employees who talks about what to do you know if there's an air or just the whole process of that because I know the facilities that I worked at nobody has ever done it until the time that it's

happened so what education are we providing from the get-go that maybe change practice further down absolutely so we risk management speaks at nursing orientation for us anyone else do they have just to talk about oh sorry that's

okay Dartmouth Hitchcock Medical Center up in New England and we have an error prevention training class that's required by all new staff but we also have made a huge push that all veteran staff have to go as well and we're like

at 90% it's a two-hour training and it talks about all different types of error prevention and then it also talks about our reporting system we also are starting to look at code lavender if anyone's heard about that but that's the

second victim so we're supporting our nurses through errors and doctors you know technicians technologists but we have a really great just culture I mean sometimes of course it's thought to be punitive but I actually as a nurse

manager do all of the reporting systems for quality and safety for the whole department and we have at 9:30 we have a daily safety brief and everyone from the hospital every department comes and reports out any safety issues and then

oftentimes in real time we're actually getting together with the different parties to say okay what can we do what was the failure we also have a very robust our see a root cause analysis or when we

have something that goes to a report that's pretty serious we will have that we get a lot of people in the room including the people that were involved in it and it's to look at where do we systems failure where is that and then

after that oftentimes we'll do a cap so we'll grab a group of working together to say we need to change our policy or change the standards in which we're working because it's it's not ever proof it's fabulous thank you so much for

sharing that okay thank you all very much I appreciate you coming [Applause]

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

pictures that we put up here this is our

simulation right so this is our mentis and I think it's very similar to what we have out in Hall there but this really adds a value to practicing and simulation our texts and our nurses were never able to practice during real cases

on real patients injecting contrast using radiation I mean those are the things that we really can't do theoretically and ethically right so this simulation piece was an important and valuable factor where we are able to

identify angiograms injecting contrast not really but simulation and using fluoroscopy again simulated fluoroscopy which is the best part of it is that the nurses can't use the fluoroscopy in Arizona and the techs can administer

medication so this is just an environment of playing this is our sandbox this is where we can come together and feel how the others work so that stimulation piece was was pretty

valuable this program is designed for an interprofessional growth with our scopes with our t's with our ends with providers with fellows with other adjunct staff that are in the lab so we wanted to grow that and and provide that

environment we don't want to segregate the nurses and the text we don't want to segregate that we want to be a team there shouldn't be a role attached to you when you're working everybody works as a team we do understand what our

licenses are we do understand how far we can go with our license but that should be the only thing that differentiates us between working in the lab so we wanted to bring that forward as well and the other piece is creating the simulation

scenario working with the mentis simulator and our simulation partners we wanted to develop a scenario for each of our cases so we we've picked five major cases that we do in that in the cath lab a left heart cath a right heart cath

maybe a pacemaker and we developed a scenario for our learners to actually follow and follow along with so from you know bringing your patient from pre holding or into the lab following them with their lab work making sure the

consents are signed all those priorities that we need to have for the patient to actually come into the lab and continue with the procedure so we did a mock scenario for all of the a mock simulation scenario for all of those so

all those cases that we did so that was also helpful for them to guide guide our learners this is the actual photograph

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

apply for every situation

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

something so the airway assessment is

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

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

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

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

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

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

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

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