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The Impact of Twitter on Our Specialty | Twitter Case Files: Impact on our specialty and how to expand our reach
The Impact of Twitter on Our Specialty | Twitter Case Files: Impact on our specialty and how to expand our reach
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How We Established our Practice Guidelines | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
How We Established our Practice Guidelines | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
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Project Interventions & Improvements- Lab Reduction | IR Lean Sigma Team Improves Patient Experience and Throughput
Project Interventions & Improvements- Lab Reduction | IR Lean Sigma Team Improves Patient Experience and Throughput
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Background on Interventional Oncology | Interventional Oncology
Background on Interventional Oncology | Interventional Oncology
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Practice Guidelines | Procedural Sedation: An Education Review
Practice Guidelines | Procedural Sedation: An Education Review
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Indirect Angiography | Interventional Oncology
Indirect Angiography | Interventional Oncology
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Combining Guidelines with What You Know | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
Combining Guidelines with What You Know | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
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Innovative Learning, Testimonials, and Program Results | Cath Lab Academy: An Adjunct to an Orientation Program Using an Interprofessional Approach
Innovative Learning, Testimonials, and Program Results | Cath Lab Academy: An Adjunct to an Orientation Program Using an Interprofessional Approach
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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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Mentice Simulator | Cath Lab Academy: An Adjunct to an Orientation Program Using an Interprofessional Approach
Mentice Simulator | Cath Lab Academy: An Adjunct to an Orientation Program Using an Interprofessional Approach
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Treatment Options- TransCarotid Artery Revascularization- TCAR | Carotid Interventions: CAE, CAS, & TCAR
Treatment Options- TransCarotid Artery Revascularization- TCAR | Carotid Interventions: CAE, CAS, & TCAR
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Cath Lab Academy Curriculum | Cath Lab Academy: An Adjunct to an Orientation Program Using an Interprofessional Approach
Cath Lab Academy Curriculum | Cath Lab Academy: An Adjunct to an Orientation Program Using an Interprofessional Approach
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Theories on Accident Causation | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
Theories on Accident Causation | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
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Project Interventions & Improvements- Patient e-Surveys | IR Lean Sigma Team Improves Patient Experience and Throughput
Project Interventions & Improvements- Patient e-Surveys | IR Lean Sigma Team Improves Patient Experience and Throughput
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Benefits of UFE | Uterine Artery Embolization The Good, The Bad, The Ugly
Benefits of UFE | Uterine Artery Embolization The Good, The Bad, The Ugly
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Introduction- Innovation & Application of Nursing Dashboards | Innovation and Application of Real Time Nursing Dashboards
Introduction- Innovation & Application of Nursing Dashboards | Innovation and Application of Real Time Nursing Dashboards
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Q&A- Procedural Sedation | Procedural Sedation: An Education Review
Q&A- Procedural Sedation | Procedural Sedation: An Education Review
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MRI Safety & Screening | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
MRI Safety & Screening | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
aneurysmassesscardchaptercontraindicateddefibrillatorsimplantimplantsinjectedinjectionmraMRINonepacemakerspatientpatientsradioactiveremovescanscreenedshieldingzone
Q&A Bleeding Risks | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
Q&A Bleeding Risks | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
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The Path Forward | Uterine Artery Embolization The Good, The Bad, The Ugly
The Path Forward | Uterine Artery Embolization The Good, The Bad, The Ugly
chapterembolizationfibroidfibroidsgynecologistgynecologyhysterectomyinterventionalNoneobgynPathophysiologypatientpatientsprocedureproceduresprogramsurgicallyworkup
Renal Ablation | Interventional Oncology
Renal Ablation | Interventional Oncology
ablationcardiomyopathycentimeterchaptereffusionembolizedfamiliallesionmetastaticparenchymalpatientpleuralrenalspleensurgerytolerated
Administration | Procedural Sedation: An Education Review
Administration | Procedural Sedation: An Education Review
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Introduction to Respiratory Compromise | Respiratory Compromise: Use of Capnography During Procedural Sedation
Introduction to Respiratory Compromise | Respiratory Compromise: Use of Capnography During Procedural Sedation
anesthesiachaptercliniciancrnainterventionalmajorityMedtronicNonepresentationslides
Burnout | Gold Medal Lecture - Health of Technologists and Nurses and the Role of Compassion in an AI Focused World
Burnout | Gold Medal Lecture - Health of Technologists and Nurses and the Role of Compassion in an AI Focused World
baltimorecanadachapterglobalinterventionalNoneoccursphysiciansradiologysedatedspecialtysustainablewarming
Human Factors That Reduce Situational Awareness | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
Human Factors That Reduce Situational Awareness | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
awarenessbluntchaptercommunicationfactorshumaninstrumentMRINoneoverloadpatientpreciselytaskversus
Q&A- Documentation, Before and After results, Leadership, Culture | Innovation and Application of Real Time Nursing Dashboards
Q&A- Documentation, Before and After results, Leadership, Culture | Innovation and Application of Real Time Nursing Dashboards
accomplishchapterculturedatadocumentationdocumentinginterventionalleadershipmanagermodalityNonenursenursesnursingpatientphysiciansprojectprojectsradiologyroundingteamtechnologisttechnologists
The Ways to Recanalize the Below the Knee Vessels | AVIR CLI Panel
The Ways to Recanalize the Below the Knee Vessels | AVIR CLI Panel
ablationanalogantibioticarteriesarthritisassessaveragebasicallychapterclinicaldissolveemboembolizationembolusinfarctinjectinvestigationalkneelateralmedialmrispainpalpatepatientpatientsprocedurepublishedradiofrequencyrefractoryresorbablescalestudy
Transcript

hi everyone I'm so excited to be here my name's Michelle mana B's I am a UT Houston fourth-year resident and I'll be headed to Yale for AI our fellowship in the fall and I'm happy to start us off this afternoon with the impact of Twitter on our specialty in how we can

expand our reach and so just a little bit about the platform that we've all chosen Twitter's a micro blog 280 characters for fewer images and short-form videos what this says to me is this is perfectly tailored for our

fast-paced highlights only major learning point objective when sharing about our favorite subject and just to give a little bit of perspective in 2018 206 users had hashtag irad in their bio so they were irad users right and March

of just this year we have over 1400 a few more stats for you so these are from just last week so a total of seven days we have 500 total tweets with hashtag irad and as we are an image-based specialty obviously the text with the

tweets with just attacks are not very many and but what I wanted to point out I'm really proud of there are 78 original contributors and 71 percent of those tweets were retweets so there's 78 people putting the

information out there and the rest of us are doing a really good job supporting them so what is Twitter done for our specialty three major points networking education awareness and collaboration so I'm a little more familiar with

Instagram so I have over a hundred twenty thousand followers on Instagram and so so this is not as familiar to me right and when I joined Twitter last year sar I had one follower and it was my mom and

I so I posted this on my Instagram I said I just have one Twitter follower what could I do help right and just over a year here we are the most recent stats of my page had significantly grown and that just speaks volumes on how much

we've grown together expanded growing evolved as a community and a presence on social media and I have 964 friends now if you're not friends with me let's be friends right now

oh and so next education and awareness so this page the interventional initiative if you are not following I suggest highly suggest you look into it so this is a nonprofit organization that increases awareness for minimally

invasive procedures their graphics are really patient friendly really easy to understand and this is the first thing you see when you go onto their website so if a patient were to just go on and say why how'd you know something my

doctor said something's wrong with my lungs is there a minimally invasive procedure for that most likely yes and all they have to do is just tap on the organ system that they identify with and they have an easy explanation of the

procedure that they're about to get or a procedure that they might be interested in and a finally collaboration and one of my favorite hashtags that really exemplifies this is hashtag leave your specials here at the door and I met dr.

Sabet I set this year and it unites as more as a disciplinary multidisciplinary group more than just this is my patient it is all of our patient and how can we work together to make sure that our patients have the best outcome and so we

are identifying more as patient centered and not specialty Center and so this is a really good positive aspect of collaboration between specialties and another aspect that I really love collaboration in a way that we get to

break down boundaries geographic boundaries right meet people that we necessary wouldn't get to meet be friends with people we wouldn't be friends with other Hawaiians and have a little fun do we have audio for this oh

darn well pretend Full House is playing in the back and we're are gonna we're gonna watch the whole thing it's so much cooler with the south kid so just you know bringing some fun you are especially doesn't always have

to be cases and always have to be serious and to show that we're humans too and so finally I want to speak a

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

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

no thanks to the avir we really wouldn't be able to do anything that we can without y'all so I take great great pride in sharing things from our perspective said you folks can start contributing your own thoughts your own opinions and your own vision during

these cases I think it's certainly something that I've appreciated since the first day of doing invention where do you all do so having said that we're just a smidge in the behind side so we'll try to focus today is mainly a

survey to stimulate everyone in terms of what's actually happening on the other end of the catheter with respect to the patient why are we doing these things where's our role and I think that's gonna add hopefully some value the next

time you folks step in on one of these cases alright so as you know dr. daughter first was able to visualize the inside of a blood vessel and find a stenosis and a lady who had limb ischemia and then was able to use a

dilator to fix that so obviously that gave birth to interventional radiology so we started taking pictures of tumors just to diagnose tumors back in the day before we had actual imaging and what we found

was well if tumors have a high demand for blood just like anything else what happens if we take away that blood and this is a 1975 image of renal cell carcinoma is to call them hyper and if Roma's back then but basically the

concept of interventional ecology was born the moment you could do something to make the environment for the tumor less hospitable and to try to palliate patients if they weren't subject to the the gold treatment standards like

resection in this case so fast forward to 2016 there was a huge study was International where they looked at over 3 000 patients who have primary liver cancer or her pata cellular carcinoma and what they found was that regardless

of where but if you sum all the treatment decisions that are related to those patients about 70% will see treatment by an interventional radiologist as you know that was a astounding amount

so si are listened to a lot of these types of messages even outside of obviously oncology basically we realize that there's a tremendous responsibility and the best thing to do is to dedicate ourselves fully to that and that's why I

think with IR now is a separate medical specialty we're going to start seeing more of the clinical involvement of this and certainly think the caseloads going to go up so why interventional oncology

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

to talk about is indirect angiography this is kind of a neat trick to suggest to your intervention list as a problem solver we were asked to ablate this lesion and it looked kind of funny this patient had a resection for HCC they

thought this was a recurrence so we bring the comb beam CT and we do an angio and it doesn't enhance so this is an image here of indirect port ography so what you can do is an SMA run and see at which point along the

run do you pacify the portal vein and you just set up your cone beam CT for that time so you just repeat your injection and now your pacifying the entire portal vein even though you haven't selected it and what to show

well this was a portal aneurysm after resection with a little bit of clot in it the patient went on some aspirin and it resolved in three months so back to our first patient what do you do for someone who has HCC that's invading the

heart this patient underwent 2y 90s bland embolization microwave ablation chemotherapy and SBRT and he's an eight-year survivor so it's one of those things where certainly with the correct patient selection you can find the right

things to do for someone I think that usually our best results come from our interdisciplinary consensus in terms of trying to use the unique advantages that individual therapies have and IO is just one of those but this is an important

lesson to our whole group that you know a lot of times you get your best results when you use things like a team approach so in summary there are applications to IO prior to surgery to make people surgical candidates there are definitive

treatments ie your cancer will be treated definitively with curative intent a lot of times we can save when people have tried cure intent and weren't able to and obviously to palliate folks to try to buy them time

and quality of life thermal ablation is safe and effective for small lesions but it's limited by the adjacent anatomy y9t is not an ischemic therapy it's an ablative therapy you're putting small ablative radioactive particles within

the lesion and just using the blood supply as a conduit for your brachytherapy and you can use this as a new admin application to make people safer surgical candidates when you apply to the entire ride a panic globe

thanks everyone appreciate it [Applause] [Music]

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

then another question is we have a high turnover because when we throw them in they think that I are in cath lab is a piece of cake and then they get a rude awakening and with all there's a lot to do rather than just angling and pushing

drugs so you said that this simulator is supposed to help them learn as far as you know turning over so there's two pieces to that question that I really enjoy the simulation is geared towards identifying and understanding how our

functionalities are done right what we do physically in the lab the misconceptions of coming to a cath lab or an interventional radiology suite is that what we're glorified sedation pushers and button pushers right so we

just sit back and we just watch your patients in the lab while the doctor does all the work so we really try to actually we do change that mentality during our first week in our didactic and our lectures once our learners are

in the program about the third week we we all come together and they all come together and it's the same reaction every single time as oh my gosh this is amazing this is a lot this is overwhelming how am I ever going to

learn all of this so it is bittersweet because we're hoping that we're not intimidating to let them leave we want them to stay we want to encourage them but our simulation piece also gives it that solidification now now you really

see what happens in the and and practice so I think it kind of reduces some of the anxiety once they get into the lab and I just want to add to that really it's again the learning doesn't stop once they're done this

right they're gonna continue to learn and it's and a lot of times we've mentioned to them just to say you know what it's what you put into the program to or what you put into your learning understanding the role understanding

what you're gonna do understanding procedures etc you have to really do your homework because you know I mean people just think oh is just spoon-feed it to me but the reality is you have to actually put a lot of effort and really

learning so I just - back for as an example really looking at the cardiac views when I was first new to the cath lab I really wish I had something like this that I would have been able to say oh I'm understanding what I'm really

truly looking at now and like what you know the role of the RT is so I just learned that by asking questions continuously so that's I think that's one of the biggest things - and so traditionally that's kind of the route

that a lot of people take is that it's just again on the job so having this essentially formal structured program really has helped as an adjunct to their learning last question do you have a

fun for our learners too so what we did actually just this last cohort was we wanted to integrate basically some

innovation into our program and so basically we used a social media platform and so within our system it's called Yammer and so we warily wanted to like take pictures make it fun have comments what did they learn what kind

of things did they still have questions about different polling questions so really trying to get them more engaged and really understanding and really kind of looping back with each other and trying to network as well so that was

part of why we're using that platform as well we also invited previous cohorts to come back and really like maybe share some tips and tricks that they've learned so that this is still growing and so we're trying to this in a

different method and we also at the very end we really want to celebrate success so we really just truly say you know congratulations to our graduates essentially and it gives them that feeling of empowerment that they have

had some more formal training and that now that this and they know that they're not truly competent after this but it's just really that extra training that they get for the program and these are some of the testimonials

that we've had from our learners based on the evaluations and really it was just integral introduction to the cath lab and so a lot of times they feel very overwhelmed and as you can see this person you know had a better grasp of

the whys of the house and that it's not just the task anymore so they really understood like more that theory to practice component of it you know with us being you know working in the cath lab previously and those subject matter

experts our learners could really ask those questions and and based on our experiences and so they they felt like they could ask any question for that matter and they're just really that they recommend this to everyone who comes who

is new to cath lab for that matter and so really some of the other results that we have from our program too is a reduction in our turnover rate so at the beginning of January of last year the turnover rate as a system overall was 16

and a half and that dropped to 14 at the end of the year so it did have somewhat of a significant impact on our turnover rate within the whole health system in the cath lab and so what's the future now of our program so really it's based

in Phoenix for the majority of it and so now how do we get it to our partners who are down in Tucson and in the northern Colorado region so we're looking at different methods of how can we provide that virtual education how can we

provide it either via some sort of online platform but then when it comes to that time to the hands-on component that's the piece that we're still trying to figure out a lot of and like really how do we work with either a simulation

partners in those regions or how do we maybe videotape or work with our preceptors etc those are things that we still need to look at also - there's also been talk about having a program for our interventional radiology as well

in our electrophysiology so Academy is based on those again so you know trying to develop this program successfully means that we definitely need to have some metrics as you know with any program success is important so how do

we measure that success so focusing on those metrics and those outcomes and especially patient outcomes how did our program really impact the learners did it impact the learners at all um so what we've decided

is that I think measuring evaluating their competency at three months six months nine months and 12 months will give us enough data to ensure that the program was a success some of the tools that we developed on measuring those

outcomes is a post capability survey and this will be used following the Academy and following our cohort cohorts identifying any gaps in their learning and in their orientation also we want to make sure that we follow their pathways

so each of our learners on-boarded will have a pathway and milestones that they will follow with their preceptors and with their managers just to make sure that they're on track and that they need to be where they need to be at that time

we also have our annual competencies that again our new hires will receive upon hire and again following that one-year mark making sure that they are competent and still competent and some of the skills that they've learned in

the Academy obviously and on the job and then our advanced compensate through certifications and I mean I think that's really important this is the way of our future and having those advanced certifications is pretty important so we

really want to focus on how can you advance in the cath lab or an interventional radiology for that matter and develop those skills to help you get your certifications so this is an example of our post capability survey so

after we've completed the Academy with our learners we really want to go back and follow up with them so this is an example of some of the skills that we've had that we have in the cath lab such as procedural sedation close your devices

hemodynamics etc we want to ensure that they have the initial observation using the level of competence survey score from novice to expert and determined by their managers or their preceptors will ensure that they are

moving in the right direction so their initial observation is what they measure followed by subsequent of observations and that is also based on what the managers and the preceptors will feel as subsequent how many subsequent

observations they may need throughout the year to either throughout their orientation process or throughout the 12 months that we want to measure and so just to add on again about the certification so again we want to make

sure that we include so nurses the artis and then what certifications nurses and our teas can get so we really wanted to make sure that they are aware of the different types of certifications out there not that they're gonna get it

right away they need a little bit more experience first but this is just an opportunity for them to again on their pathway or milestone to kind of something to achieve and for anyone who's a big Disney fan like me

you see Hidden Mickey don't you okay

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]

of the simulation and mentis simulator that we purchased that our system and purchased it's used in conjunction with

the cardiologists and first second third year cardiac fellows interventional fellows who also have the opportunity to practice on this but what I really liked about this and what really surprised me is how real it

is for learners and for our texts that come in our technologists using this piece to move the C arm to move it left to move it right injecting contrast which is actually air but you know we want to say it's contrast I'm moving the

table understanding how to pan the table how to move the CRM there's a lot of different functions that they can use collimation magnification so this board this panel is pretty much what they're going to do on a daily basis so this is

extraordinary and the picture next to it shows us some 3d dimension three-dimensional pictures of the coronary arteries laid out in different projections so depending on how you move your C arm you'll be able to see the

different angles of your coronary arteries again this is live real-time simulation 3d dimensions so we don't have to actually inject the contrast to visualize our coronary arteries in our a Horta there's a function button that you

can push and it automatically displays the three dimensions so it makes it easier for us to identify those arteries without having to inject and show the different views so it's fascinating in more pictures that showing doctor Lee

came who came to Phoenix Banner University Phoenix to help demonstrate so this is our first week after we've introduced the mentis to our learners and had them play with some of the functions again following up with dr.

Lee's visit he's the one that questioned our staff our learners and reiterated what Michael and I have taught in the first week so basically just understanding and reiterating everything that we went through and having our

learners hear it again from the physician what does he want how does he expect his staff to participate in how do his how does he expect his so what are the expectations of our learners so he was really forward he

asked them great questions they answer them because we taught them but we also showed that he also was able to show them some techniques that they as physicians would like the learners to know right so um he is the clinical

expert obviously so it was really nice to see them interacting together and answering questions again just another photograph of one of our learners using the mentis and showing the actual x-ray view on the left and showing the 3d

dimension on the right these are this is our photograph so we took these pictures during our last week of our programs so this is our final wrap-up putting it all together so we basically took them to the lab we we borrowed one of the labs

we asked our operational leaders if we could borrow one of the labs they weren't using that day and we came in and we set it all up we wanted to make sure they knew how to open a tray how does that how to set the table how to

set the back table how to prep the table how to get their power injections their med rads or their assists put together so we really went from A to Z during this wrap up final simulation study so our learners gound and glove they put on

their PPE and we did have the mentis underneath the drape so they were able to drape as if it was a real patient and also manipulating those wires so we had our cardiology fellow interventional fellow first I think it was first year

in second year who came to assist they were gracious enough to come in and help us assist that piece while Michael and I could focus on the learners helping them navigate through that lab calling out for supplies calling out for wires

calling out for stents calling out for balloons so it was pretty realistic and I think I think our learners really enjoyed that this is just another view of our table being set up one of our learners

scrubbed in she was an RN and she was learning kind of moved the table again you don't really get to do that in real life but in simulation all is game so they got to play and here's an image of our cardiology fellow it's not playing

so what it shows is the simulation of the angio angiogram of the coronary arteries so while we inject the contrast you can see the arteries filling in that simulation unfortunately we can't seem to get it to play again more pictures of

me teaching them how to move the table and the position that they needed to be in so and so we also wanted to make it

quick I did want to mention t-carr briefly and try to get you guys closer to back on time this is a hybrid procedure this is combining the surgical procedure we talked about first and carotid stenting it takes combined

carotid exposure at the base of the clavicle or just above the clavicle and reverses blood flow just like we talked about but tastes slightly different technique or approach to doing this and then you put the stent in from a drug

carotid access here's the components of the device right up by the neck there is where the incision is made just above the clavicle and you have this sheet that's about eight French in size that only goes in about us to 2 cm or 1 and a

half cm overall into the vessel and then that sheath is sutured to the the chest wall and then it's got a side arm that goes what's labeled number six here is this flow reversal urn enroute neuroprotection kit it reverses the

blood flow and then you get a femoral sheath in the vein right in the common femoral vein and you reverse the blood flow so this is a case a picture from our institution up on the right is the patient's neck and that's the carotid

exposure and the initial sheath is in place so the sidearm of that sheath is the enroute protection system which is going up up at the top of the image there we're gonna back bleed that let that sidearm of that sheath continue to

bleed up to the very top and then connect that to the common femoral venous sheet that we have in place there's a stepwise of that and then ultimately what we see at the end of the procedure is that filter inside that

little canister can be interrogated after and you can see the debris this is in the box D here on the bottom left the debris that we captured during the flow reversal and this is a what we call a passive and then active flow reversal

system so once the system is in place the direct exposure carotid sheath in place the flow controller and AV shunt in place you see the direction of blood flow so now all that blood flow in that common carotid artery is going reverse

direction and so when you place a sheath or wire and and ultimately through that sheath up by the carotid artery there's no risk for distal embolization because everything is flowing in Reverse here's a couple

case examples ferns from our institution this is a patient who had a symptomatic critical greater than 90% stenosis has tandems to nose he's so one proximal at the origin and one a little bit more distal we you can see the little

retractors down at the base of the image there in the sheath that's essentially the extent of the sheath from the bottom of that image into the vessel only about a cm or two post angioplasty instant patient tolerated that quite well here's

another 71 year-old asymptomatic patient greater than 90% stenosis pretty calcified lesion a little more extensive than maybe with the CT shows there's the angiography and then ultimately a post stent placement using the embolic

protection device and overall the trials have shown good good safety met profile overall compared to carotid surgery so it's a minimum minimal exposure not nearly as large the risk of stroke is less because you're not mucking around

up there you're using the best of a low profile system with flow reversal albeit with a mini surgical exposure overall we've actually have an abstract or post trip this year's meeting this is just a snapshot of that you can check it out

this is our one year experience we've had comparable low complication rates overall in our experience so in summary

so just as Michael said we've taken a lot of time to develop this program and I think having the background that we have in cath lab as an arti a technologist and as an RN we've pretty

much realized what we need to build this program especially coming from general radiology and entering the cath lab you know I didn't know what a sheath was so if I would have had a program like this I think I would have been a little bit

more successful I'm transitioning into the cath lab the way most of our learners have so what I've done and what Michael and I've done we've reached out to a few of our interventional cardiology partners in the system who

were very passionate about developing a program like this not only does it help our learners and our future staff it does help our cardiologists and our physician providers and fellows who are working with the staff hoping to be a

seamless flow so what we've done is our infant stages of brainstorming you know what do we need to produce a great Academy what do we need to focus on as staff as physicians and so we asked our physician partners what do you want to

see when we're building this program well they want to see new to service or staff in general kind of hitting the ground running right so we want to teach them how to scrub properly how to use the equipment properly how to manipulate

wires how to manipulate catheters learning how to set up power injections anticipating what's coming next during a procedure during a complicated case so those ideas were really essential in developing our program and trying

identify what we can do first for our learners and how we can make them feel comfortable some of these radiology technologists that are coming in from general radiology have no idea what they're coming into there's a little bit

of a difference just knowing that some nurses that do attend the schooling may have heard of you know what an EKG is and what a waveform is whereas some of our red tags have not so we really needed to hone down on the basics okay

so these are some brainstorming ideas that dr. Lee and I and Michael had put together and said here's the pathway we want you to follow follow okay so our again we went from a six-week program now down to a three-week program and

incorporating simulation and so we took a lot of what we wanted to and like what we would recover in our first second and third week and here we're going to go into more detail so really week one as

riesen comes to us and he talks about

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

thank you I'm thinking for an excellent presentation my question is around obviously it has to marry up with recruitment and the cause so staff

recruitment and so how many how often are you running the course in how many participants are typically on each course because I would imagine that number could vary significantly from each course so I hope I understood you

right because again there's a little bit of an adherence did you ask how often we do offer one program and how many participants do we usually have yeah yes so we are running the program three times a year

and we have a minimum of four participants and so hopefully if we can get eight to seven to ten usually is our optimal range but we've had a class and a program with four but usually it's about five to seven in the class so what

happens if there's staff get recruited do they just have to wait or do they start training on the job and then three weeks later they start up I mean so theoretically our our employees are hired on from into the cath lab by our

management team and depending on their experience so if we have less than a year of kappab experience you're eligible to join the program okay so preferably we'd like them to have at least one to three months

already in the lab before they come to us and it helps them identify some of the items that we're talking about some of the content that we're referring to as opposed to coming in day one from interventional or from general radiology

or from the IDI as a nurse and not understanding some of the components that we're talking about thank you that was really helpful great thank you she asked what I was pretty much thinking - and have you considered

branching out where other Hospital employees could come and learn for a fee at your campus around the country that's a great question so I think that's one thing that we may bring forward to our educational leaders and say is this

something that maybe we can start offering to other facilities within the metro area etc so that's a great we were actually just talking about that the other night so thank you it's it's very interesting thank you and here's our

morning I'm Molly Perdue ba I'm one of the procedure nurses and one of the best

things we ever did was to adopt this smart dynamic electronics patient surveys previously we used the regular paper service that most hospitals use and they were mailed to the patients about four weeks after the procedure and

I tell you no one ever mailed them back to us so we are lucky if we get one or two each month so we we never had a real patient feedback so we got lucky our hospital was starting a small pilot for this brand-new East surveys and they let

us join the pilot group it was really fascinating it turned out that these two doctors from North Carolina invented this and these are like short dynamic smart service that are texted or emailed to the patient the day after the

procedure so the survey consists of 10 quick questions in the free text box so no more paper no more snail mail and the patient's get the survey right away well it's still fresh in their minds and not four weeks later so on this slide are

our 10 current survey questions and one cool feature is that we can change these questions at any time and we can that we can pull from a large question Bank but for a clear project we use the same 10 questions so we had consistent pre and

post data they also have a great website that we can access so we can see the patient scores patient comments and they even have everything graphed with trends over time so we can see whether we have improved this slide all the patient

comments are emailed out to the multidisciplinary multi-departmental team every month so when I opened my email I see more than a hundred patient comments so the team is usually excited about

opening the email every month and you look for their names and staffer of often mention and compliment complimented by patients so for this graph it represents patient East Survey top box scores for the questions in a

timeliness category so we saw 24 percent improvement for the question my care team kept me informed of delays and we we also saw 36 percent improvement for the question my procedure started on time so now I'm gonna hand it back to

Allison to share additional project results in our conclusion

Sean I know you have not seen these slides at all you wanted I John can talk about this with his eyes closed so it's

not like there's anything but this is the data that was published from the Jade publishing jvi are from what Sean has written and it's just the current standards relating to what you should be expecting what we tell our patients that

they should expect for outcomes as it relates to uterine artery embolization again I'm not really here to try to point this I know you can google these you can get the information yourself but just to say that all of our procedures

have risk and we need to be clear with our patients about them now I believe that with all of these risks combined the benefits of doing uterine fibroid embolization for most patients is far greater than the risk and that's why I

really do have my practice so these are the benefits right shorter hospital stay and I would say more cost-effective and that is really debatable because gynecologists have become smarter and smarter now they're doing like same-day

hysterectomies if you have a vaginal hysterectomy then maybe a UFE is not as cost-effective because they don't have to do an MRI beforehand and they don't get an MRI afterwards and do all of that anyway and if you look at the long-term

cost of that then maybe having a hysterectomy in some patients could be that but we know for sure that patients are more satisfied when they get a embolization procedure than in my MEC to me not in the beginning run because the

procedure can be very painful that is not the procedure itself is painful but post embolization syndrome which could last anywhere from five to seven days can can be very painful again this is the comparative data that was published

by dr. Spees who is our gold medal winner this year understand a lot a lot of work in this space has allowed us to have this conversation with our gynecology partners but also with our patients as we talked about like when

can you return to work how long are you going to be all for you know am I going to need extra child care or whatever how long would I be in the hospital this information helps us to inform our patients about that then on average

you'll stay in the hospital around you know a day or so and most uterine artery embolization procedures are same-day procedures and interventional radiologists are doing these in freestanding centers as well as other

providers without any issues so we're almost down to the end we know that fibroid embolization is proven to be an effective and durable a procedure for controlling patient symptoms it's minimally invasive and it's outpatient

most patients can go back to some normal activity in one to two weeks it has a low complication rates and some patients mein neatest to surgery and should have surgery so in our practice we send around 1/3 of our patients or so to

surgery and the reason that that is that high is that patients are allowed to come and see myself or dr. de riz Nia from the street they do not have to be referred from their gynecologist and so they're just coming from the street then

you will be referring them to a gynecologist because of some of the things that may not make them a good candidate for embolization such as this

how do I become a cath lab nurse or RT and so the traditional route really was you know if you worked in as an arti worked really general radiology or you worked interventional radiology or if you were a nurse you could come from ICU

or the emergency room pack uor or PC you are progressive care and work with your preceptors get that on-the-job training and so again there's that whole you know rich waiting you know maybe bad behaviors and creating shortcuts etc and

then you have your cath lab staff so really the early beginnings to our program kind of was twofold so we had an existing virtual program which was basically some modules online working with one of the textbooks that we have

and really working with the preceptors so then we decided how can we create this pipeline for new RTS because we're having a huge shortage of RAD techs and so initially our program was six weeks and then we kind of as we whittled it

down we can went into this three week program now and it's basically an adjunct to their orientation program it doesn't take the place of it it just adds into it and so now the other thing too is what we're looking at is how does

this look like in the future and how do we really truly impact our patient care outcomes so now when someone says how do I become a cath lab RN or RT we have again the traditional route but now we've added in this systemized the

standardized cath lab Academy working with our preceptors and now we have staff our cath lab staff and so in

good morning everyone my name is Jeanne Bulger and I'm the interventional nurse manager at dartmouth-hitchcock Medical Center and also the section supervisor of ultrasound and mammography I've been dartmouth-hitchcock about eight years four of which has been in my

current role hi everyone I am Tomi ocean Koya I am the service line quality specialist in radiology I've been with dartmouth-hitchcock for about six years I started out as a performance

improvement consultant at our Valley Institute and over the about the last three years I've been working in radiology managing a quality program across the multiple sites for our service line good morning I'm Chris

Kevin Logue I'm the operations manager at dartmouth-hitchcock for those of you don't know we're in Lebanon New Hampshire and we came from snow so we're very happy to be here I have been the operations manager for about eight or

nine years I was also the IR interventional nurse manager supervisor I was an interventional nurse and a critical care nurse so I'm very old I've been doing this for a long time so very happy to be here so let's start on

our journey in the innovation and application of real-time nursing dashboards so when I think about my journey I became a nurse to take care of people and with people there are always stories but typically data doesn't

always connect to those stories so today we are hoping to take you on a journey to understand how we've been able to use data to tell meaningful stories that show how our staff and patients are linked to organizational strategy we

have four objectives for you today the first one is to learn how to align strategy and data across all levels of the organization application of dashboards of the frontline would not be effective without this alignment second

numbers have feelings and tell their story we hope that you will learn as nurses that we can tell stories behind the numbers that can help us take better care of our patients the third objective

building and designing a nursing dashboard we hope that you will learn that we at dartmouth-hitchcock embarked on this journey to build meaningful dashboards using multidisciplinary team work and the last objective our

dashboard look interpret apply and assess model is to hope that you have learned how to apply the dashboards in real time to translate the numbers into meaning and purpose for the frontline staff everyday work the diagram on the

Left represents the amount of time it took for us to complete each objective in this project now hands off to Chris to talk about strategy Thank You Jeanne

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

really did have an isotope injected we

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

different applications renal ablation is very common when do we use it

high surgical risk patients primary metastatic lesions some folks are actually refused surgery nowadays and saying I'll have a one centimeter reno lesion actually want this in lieu of surgery people have

familial syndromes they're prone to getting a renal cancer again so we're trying to preserve renal tissue it is the most renal parenchymal sparing modality and obviously have a single kidney and a lot of these are found

incidentally when they're getting a CT scan for something else here's a very sizable one the patient that has a cardiomyopathy can see how big the heart is so it's you know seven centimeter lesion off of the left to superior pole

against the spleen this patient wouldn't have tolerated bleeding very much so we went ahead and embolized it beforehand using alcohol in the pide all in a coil and this is what it looks like when you have all those individual ice probes all

set up within the lesion and you can see the ice forming around I don't know how well it projects but in real time you can determine if you've developed your margin we do encompass little bit of spleen with that and you can see here

that you have a faint rim surrounding that lesion right next to the spleen and that's the necrotic fat that's how you know that you got it all and just this ablation alone caused a very reactive pleural

effusion that you can see up on the CT over there so imagine how this patient would have tolerated surgery pulmonary

timing of a minute administration is that you need to know the drugs time of onset peak response and duration of action and titration of drug to effect is an important concept so you need to know whether the drug you just gave hit

its peak effect before you start Rideau seing them that concept is called Li and C to peak drug effect and all that's saying is that you just want to make sure that you're hitting the peak effect before you redose if you don't you can

have dose stacking which can put the patient at risk for toxicity and latency to peak drug effects can be changed by the physical physical chemical properties like we just discussed so how much it provides to protein is it lipid

soluble it's basically talking about how quickly it can get to the site of action and do what it needs to do pharmacokinetic and pharmacodynamic variability is basically just telling you that I could give one person a

milligram of versed and then give the next patient a mil a milligram of versed and they can have completely different responses and some things we can predict ahead of time and other things are we're just not going to know I mentioned the

cytochrome p450 system there are patients that have genetic variances of those enzymes that can change the way they metabolize the drug there's no way that we're going to know that beforehand the way that you deal with this or

tackle this problem is you start small assess and adjust we all know this you learn this in nursing school it's easy to add more it's always going to be worse to try to take it back you won't be able to take it back

I like this chart just because it kind of talks about the different variables that you may encounter so we already talked about the pharmacokinetic variabilities but some of the pharmacodynamic variabilities are going

to be your drug receptor status genetic factors drug interactions and tolerance when I look at drug receptor status I'm thinking methadone buprenorphine if you have a patient on buprenorphine and that receptor is occupied by the

buprenorphine it's going to cause competition for the next opioid you try to give like fentanyl we've had some problems patience in our department with this drug as far as titration is concerned

you want to administer each component individually to achieve the desired effect now this was a change for us when I first started talking about this because we used to give versed and fentanyl together every single time but

with the AFA recommends is that you give the drugs individually monitor the response and then assess accordingly this is an algorithm I found on up-to-date it's just a suggestion obviously it's not going to fit every

patient but it's just describing how you would start out with midazolam first give that time to hit the peak effect which again remember is gonna be 3 to 5 minutes and that can feel like a long time NIR so it's a little painful to do

this but it is going to I think lead to a better outcome for you and for the patient as far as their experience then if necessary give fentanyl I usually give that for the access because really I think for the most part most of the

things we do aren't overtly painful there may be painful parts of the procedure but it's not just two hours of pain or it shouldn't be and then you want to observe the patient if you gave fentanyl you really want to wait five

minutes and then redose from there so usually I just give the one dose of fentanyl and then I stick with my versed by eliminating that that double dose every time you're going to be able to go higher on your versed or your fentanyl

depending on what you need to give so that makes sense to everybody we were we were giving we call it one round versed in fentanyl one round and then by the fourth round nurses were understandably going oh good I the

patient needs more but I feel really uncomfortable and a CRNA said to me one day why are you guys giving fentanyl and versed every time it's great for the synergistic effect but you're going to hit that feeling a lot faster than if

you just give small incremental doses of versed to get them through the procedure and leading into synergistic interactions so giving a benzodiazepine and opioid together elicits a synergistic interaction you can think of

it as 1/2 plus 1/2 equals 4 in the city and that's a lot of what we were seeing we were seeing this you know give the fence alone verse said okay they're really sedated and then they're not anymore and then they're really

sedated and then they're not anymore versus this really nice steady maintenance of sedation during the procedure intra procedure you want to be

thank you Michael thank you to Medtronic for having me and thank you to the AI a your organization for having me today I seem to be having a little trouble advancing my slides so I'm just gonna get started with my introduction here we go

so I'm here's my disclosures basically I am sponsored by Medtronic to provide this Lunch and Learn for you but I am an active clinician I work actively at Yale as a CRNA and I do provide the majority of my anesthesia in what we call our off

floor locations meaning interventional radiology EP lab GI endoscopy r zh' in the operating room so I understand the challenges you face I do you know the sedation in those rooms myself so I understand the positioning concerns the

monitoring concerns and so I'm really I'm honored to be here today and I hope that I add value to your conference while you're having lunch I won't talk about anything that is off-label use everything I will present today is

evidence-based medicine and had been proven I'm not here to sell you any products or talk you into buying anything I just really strictly clinician to clinician so starting out we only have

an hour and I really want to make sure I get through everything today so I'm gonna ask if you have any questions to please hold them to the end and that's for a couple reasons because if you have a question I might even be covering that

material in subsequent slides and I want to make sure I get through the whole presentation the beginning of the talk is going to be some review material for some of you we're gonna move through the first 30 slides pretty quickly because I

understand that the majority of you are already using capnography and I want to spend the majority of our time in this presentation talking about the stuff that the advanced level the problem solving the troubleshooting and the

things that are really pertinent to your practice so that you have value that is gained from attending this presentation today

makes a difference burnout is actually a true phenomena as many of you know in

our field then it's a syndrome of emotional exhaustion depersonalization Loper a sense of low personal accomplishment that leads to decreased work effectiveness burnout is different from depression it primarily

affects one's relationship to work not to other people it can spill over into one's life outside the hospital it occurs most frequently in people who work in intense environments it occurs in physicians nurses social workers

teachers it leads to friction and personal relationships isolation from one significant other and family members I think often what we call burnout is actually PTSD and we should acknowledge it as that is it's not just my theory

others think this too perhaps what we call Burnett is essentially that our soul is kind of tired from what we see and we see things we intervene in things in moments in lives in people where sometimes we can't save their life and

this is not something that most people experience in their lives you know I have friends who are accountants or architects or other things and these sort of dentists you know and now couldn't be a dentist to be dreadful but

you know they just don't experience that the edge of things that we see so how many people in this room have flashbacks about a specific patient Wow Wow yeah you see this is I remember four or five that where things didn't work out

I remember scenes with the FBI in the in the NGO suite in Baltimore where would be bagging people's hands you know and we'll be playing The Ramones I want to be sedated but I that is normal you know that's but but you

know this is this is we have to figure out how to make this sustainable so how do you create a balance in this to make this sustainable if you look at burnout rates by specialty you see radiology it's way up there but I'm sure

interventional radiology would be even more close to emergency radiology so it affects many physicians it affects them in med school in residency it's about 40% overall during some stage of their career so how do I handle chronic levels

of stress well in Baltimore I didn't like who I was becoming and my department wouldn't let me change what I did so I decided to leave and about 2008 we moved to Canada now Canada is it's really fun actually it's

huge ninety five percent of Canadians live within 100 miles of the US border cause it's freaking freezing if you go further north you know like we're actually really looking forward to global warming global warming is going

to be good for Canada Canada is mainly moose there's lots of moose and bears there are no poisonous animals with few Cougars we have a lot of drunk québécois on high powered with snowmobiles but you know it's like Baffin Island which is

way at the top there maybe the new Florida in about a hundred years but it's a fascinating country and and it's just you know right beside Buffalo but it's it's been fun living there and exploring it and figuring out this this

new amazing place like way over on the right we have Newfoundland and Newfoundland i Irish descent with accents from the seventeen hundreds with a ton of oil and

gas so they buy stuff ski-doos snowmobiles um you know it's you've got a visit there it's it's wonderful so that's actually being a good move and my kids can walk to school I can walk the dog at night haven't seen a

gunshot wound in 11 years and it's very different flow but I had to make that change for my own health so some basic

so we have some human factors that reduce situational awareness situational

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

they travel together so that's what leads to the increased pain and sensitivity so in the knee there have been studies like 2015 we published that study on 13 patients with 24 month follow-up for knee embolization for

bleeding which you may have seen very commonly in your institution but dr. Okun Oh in 2015 published that article on the bottom left 14 patients where he did embolization in the knee for people with arthritis he actually used an

antibiotic not imposing EMBO sphere and any other particle he did use embolus for in a couple patients sorry EMBO zine in a couple of patients but mainly used in antibiotic so many of you know if antibiotics are like crystalline

substances they're like salt so you can't inject them in arteries that's why I have to go into IVs so they use this in Japan to inject and then dissolve so they go into the artery they dissolve and they're resorbable so they cause a

like a light and Baalak effect and then they go away he found that these patients had a decrease in pain after doing knee embolization subsequently he published a paper on 72 patients 95 needs in which he had an

excellent clinical success clinical success was defined as a greater than 50% reduction in knee pain so they had more than 50% reduction in knee pain in 86 percent of the patients at two years 79 percent of these patients still had

knee pain relief that's very impressive results for a procedure which basically takes in about 45 minutes to an hour so we designed a u.s. clinical study we got an investigational device exemption actually Julie's our clinical research

coordinator for this study and these are the inclusion exclusion criteria we basically excluded patients who have rheumatoid arthritis previous surgery and you had to have moderate or severe pain so greater than 50 means basically

greater than five out of ten on a pain scale we use a pain scale of 0 to 100 because it allows you to delineate pain a little bit better and you had to be refractory to something so you had to fail medications injections

radiofrequency ablation you had to fail some other treatment we followed these patients for six months and we got x-rays and MRIs before and then we got MRIs at one month to assess for if there was any non-target embolization likes a

bone infarct after this procedure these are the clinical scales we use to assess they're not really so important as much as it is we're trying to track pain and we're trying to check disability so one is the VA s or visual analog score and

on right is the Womack scale so patients fill this out and you can assess how disabled they are from their knee pain it assesses their function their stiffness and their pain it's a little

bit limiting because of course most patients have bilateral knee pain so we try and assess someone's function and you've improved one knee sometimes them walking up a flight of stairs may not improve significantly but their pain may

improve significantly in that knee when we did our patients these were the baseline demographics and our patients the average age was 65 and you see here the average BMI in our patients is 35 so this is on board or class 1 class 2

obesity if you look at the Japanese study the BMI in that patient that doctor okano had published the average BMI and their patient population was 25 so it gives you a big difference in the patient population we're treating and

that may impact their results how do we actually do the procedure so we palpate the knee and we feel for where the pain is so that's why we have these blue circles on there so we basically palpate the knee and figure

out is the pain medial lateral superior inferior and then we target those two Nicollet arteries and as depicted on this image there are basically 6 to Nicollet arteries that we look for 3 on the medial side 3 on the lateral side

once we know where they have pain we only go there so we're not going to treat the whole knee so people come in and say my whole knee hurts they're not really going to be a good candidate for this procedure you want focal synovitis

or inflammation which is what we're looking for and most people have medial and Lee pain but there are a small subset of patients of lateral pain so this is an example patient from our study says patient had an MRI beforehand

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