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The status before we created a freestanding IR Center | Creating a Freestanding Interventional Radiology Center Challenges and Considerations
The status before we created a freestanding IR Center | Creating a Freestanding Interventional Radiology Center Challenges and Considerations
The planning for creating a freestanding IR Center | Creating a Freestanding Interventional Radiology Center Challenges and Considerations
The planning for creating a freestanding IR Center | Creating a Freestanding Interventional Radiology Center Challenges and Considerations
Lessons learned in opening a new, freestanding IR Center- Lesson 1 | Creating a Freestanding Interventional Radiology Center Challenges and Considerations
Lessons learned in opening a new, freestanding IR Center- Lesson 1 | Creating a Freestanding Interventional Radiology Center Challenges and Considerations
Lessons learned in opening a new, freestanding IR Center- Lesson 5 | Creating a Freestanding Interventional Radiology Center Challenges and Considerations
Lessons learned in opening a new, freestanding IR Center- Lesson 5 | Creating a Freestanding Interventional Radiology Center Challenges and Considerations
Q&A - Creating a freestanding IR Center | Creating a Freestanding Interventional Radiology Center Challenges and Considerations
Q&A - Creating a freestanding IR Center | Creating a Freestanding Interventional Radiology Center Challenges and Considerations

my co-presenter and colleague anne mccaffrey couldn't be here this morning she recently had a baby and was not cleared to fly just yet so I will be presenting by myself wish you were here so where we began we were seeing an average of 20 to 25 outpatient

outpatients a day between multiple services vascular I our neuro interventional neuroradiology our procedures were often delayed due to lack of recovery space to move post procedure patients into several 6-hour

recoveries mostly our angiograms and our kidney biopsies would take about half to two-thirds of the available recovery space for most of the day so as you can see we did not have a lot of space for the amount of procedures that we were

performing room utilization was at a high of a hundred and twelve percent q four that's because we were doing bedside procedures on impatience as well and we were performing procedures in our recovery room too that's what we look

like so our service rapidly expanded over the past five years and created multiple problems long scheduling delays led to a delay in diagnosis and treatment for patients which led to unhappy patients and unhappy refers

located in a major metropolitan area with many major academic medical centers led to a lot of competition and we didn't want our internal referrers to send their patients to other centers prolonged hospital stays for our

inpatients led to delayed discharge until vascular access was obtained or feeding tubes were inserted and then for staffing our staff our staff was unhappy with the frequently man √łt and leadership was unhappy with the

increased staffing costs so for our

hospital schedule we wanted to provide quicker turnaround for inpatient cases and decrease the length of stay for the inpatients waiting for the ir procedures as previously mentioned for feeding

tubes vascular access and etc which they may have needed for discharge improvement for outpatients meant shorter wait times to schedule procedures and fewer delays on the day of procedure and the goals for the

radiology administration was to provide more timely and efficient care for both outpatient and impatience and to collect revenue for procedures performed at an outpatient practice so where we started planning first we wanted to look at the

data and see what we could find on freestanding IR centers which there wasn't a lot of data there wasn't a lot of data even on freestanding surgery centers although there is more limited data on outpatient surgery center safety

has led to lower reimbursement rates for certain procedures done in outpatient centers versus hospital outpatient departments surprisingly even though reimbursement for procedures performed at free

standing outpatient centers or lower than procedures performed in a hospital setting there are still compelling reasons to move towards a free-standing practice such as greater control over schedule case-mix

patient and provider satisfaction procedure reimbursement also is paid directly to the radiology department as opposed to hospital administration so what procedures did we want to offload from the hospital it was pretty

easy we wanted simple low-risk procedures that were worthwhile for reimbursement our practice generally uses the je vir consensus guidelines for bleeding adverse outcome risk when developing policies and these were used

to help judge what was safe to perform in an outpatient setting especially considering minimal data available on what is safe to perform outside of the hospital setting treatment required for common adverse outcomes were also

considered do we have the capability to treat these outcomes safely in an outpatient setting or do they require transfer to the hospital for example we needed a CT scanner for angiograms possible bleeds for kidney biopsies etc

so here's what we came up with these were the planned procedures that we wanted to perform at the outpatient center from the jie vir if i could just go back real quick you can see that they're in three risk categories

low-risk moderate and high we mostly kept it to low-risk moderate risk with the exception of thoracentesis and paracentesis and the only high risk procedure we were performing was liver biopsy and that is our graph there so

what didn't make the cut and why well the facility originally had a CT scanner planned due to a backlog of lung biopsies being performed at the hospital but this changed when considering the rate of new Mo's requiring chest tube

insertion and overnight observation as these patients would require 9-1-1 transfer to the hospital and reporting of adverse events to quad ASF which is our regulatory body paracentesis those patients are unique population requiring

a lot of outside intervention so transportation assistance Social Work did not reimburse very well they took up a lot of space and recovery as they drained as well adrenal vein samplings you need an on-site lab for that you're

running labs constantly throughout the procedure and we needed pharmacy to be able to run the Koston tropen drip and the trans arterial radioembolisation x' the Y 90s there was a lot of moving parts in order to get that going

so you need a hot lab or radiation safety on-site nuke med it just was a big undertaking to put that at the outpatient center so planning training and competencies the orientation was built from scratch by radiology RN

leadership since not covered by traditional Hospital based RN educators modeled after Hospital orientation with attention to common competencies between the two sites but maintaining one standard of care we both had eLearning

in both locations so that included annual confidence emergency management safety surgical team training communication procedural sedation capnography laser safety bariatric sensitivity competency

medication administration hazardous materials and then on-site Hospital training was originally planned for the inaugural staff for three months but it increased due to construction delays we tried to train them mostly to procedures

that would be performed at the outpatient center but they were able to see a lot of our more emergent inpatient procedures as well which i think was a really good learning experience for them and then there was also hands-on

training for medical devices the IV pumps glucometers your pregnancy tests those sorts of things know your regulatory body so you all know the Joint Commission right so we're actually overseen by quad ASF which stands for

American Association for accreditation of ambulatory surgery facilities you see why we call it quad a for short this was a learning curve for staff and administrators used to Joint Commission standards many standards similar like

environment of care credentialing sterile equipment and storage etc Joint Commission is very inpatient care centered so many regulations related to documentation intake and screening and physician oversight of physician

extenders like the NPS and the PAS they require greater oversight at the outpatient facility so that was different for us developing relevant policies there were over 350 quad-a SF regulations that had

to be written into site-specific policies I have all of those binders in my office many of the policies are similar to the hospital standards like I had mentioned before but there are some unique considerations for a

free-standing procedural Center so there's more stringent screening by the nursing staff for multiple comorbidities right we don't want anyone showing up who's just too sick to have a procedure or now has to be transferred because

they haven't been optimized our emergency transfer policy is 911 911 facility so there is no code team although we're prepared for emergencies we have a cart our staff is trained we call 911 first and then we had to have a

policy for incapacitated provider so if somebody is performing a metaphore and then drops to the floor what do you do which is unique to our Center because in the hospital you would just call the team and somebody would be able to come

and help so that's us that's the

outpatient center right there open for business so after much planning and preparation we had access to start organizing and stocking the facility in December of 2017 and our first

procedures were scheduled for January 2nd 2018 and this is when I was hired and came on that fall so this is what we looked like in the beginning those are our two procedure rooms from left to right and in the middle that's our

control area so no flooring no ceiling and I knew we were opening shortly and I took these pictures and was like I'm gonna document this because I'm going to be thrilled when we actually do open on time it just looked like we weren't

gonna get there here's our recovery room we have six stretcher bays room for storage medication refreshments we have a blanket warmer which our patients absolutely love so it looks much different now so anytime you start

something brand new there's gonna be lessons that you learn as you go along so here's some of the lessons learned and some of the challenges we faced once the center was actually open and we started moving into it we had equipment

challenges right so everyone knows this is a suction canister I took for granted many small things I set up the rooms I filled them with the equipment I knew we needed so we're gonna be sedating our patients right so I need resuscitative

equipment I need suction so I got myself the suction canisters I ordered the tubing in the yankauer I even ordered suction catheters even though I thought it would be unlikely that we would ever use it the one thing

I did not think of ordering until I tried to put everything into the room and attach it to the wall was the holder for the wall so these were the little things that I had taken for granted once I moved in that I realized I needed

another lesson learned is you can't always get what you want does anyone know what this is called or what it's used for all right it holds the drapes so initially when we opened I said you know what we need we need a drape holder

or what we call a tent maker so we said okay no problem let's look it up let's order it so we ordered we looked under drape maker couldn't find it we looked under tent maker couldn't find it Surgical drape

holder Surgical table and it's just like I mean every word possible trying to figure out what this thing is so what do you do when you need an answer and you can't find that answer you consult Google so I look up tent maker

apparently this is like a I guess it was a big-time biblical profession and this is what I got for tentmaker so out of frustration I said I'll just put in all the keywords and see what happens so I

put under the mattress surgical drape holder bendable loop and what I got was the comfort halo which is what this is called and then sometimes you can get what you want and it gets delivered on enormous pallets and you have to unload

it all break down the boxes so that winter actually was pretty mild and I remember actually standing on ladders and steps tools at box cutters this is not that the job I thought I was getting into when I got hired to come in to help

leave the site but we spent a lot of time breaking everything down and finding a place for everything this is valerka on the left and Cindy on the right there are our essays they're unique to our outpatient center our

essay stands for radiology service attendant they worked in the hospital at the front desk and took on this new role they order equipment they help maintain the supplies they move patients throughout our Center as escorts and

they generally help to turn over the rooms and just support the staff in any way that they can in an in a non clinical way so we did a lot of bonding that summer because there were no patients no other staff just goofing

around breaking down boxes and dealing with all the supplies they were amazing environmental challenges okay so now we started moving everything in and once we started to put everything in its place we found that the outlets were not

exactly where we needed them I didn't have lab cabinets in the bathrooms for the urine specimens for the hcg tests so people were walking around with their containers of urine which not ideal storage issues our narcotic cabinets

were not located in area that I thought were as close to the nurse's station as they should be and we have elevator access to our procedural floor and that's it we're located in the cellar

so that also was an issue because patients needed escort down their families needed escort down so that was a huge environment continues to be an environmental challenge for us so lesson

number two sometimes you have to break

the mold outpatient centers will never be hospitals no matter how hard we try to recreate the same kind of setting we wanted synchrony between the hospital in the outpatient center which we affectionately call the OSI our goal was

to have one interventional radiology department in two separate locations our inpatient hospital center would take care of the emergencies in the inpatient needs and the outpatient center which would have all the technology and

standard of care of a large medical center we'd be able to share information we'd have shared policies and guidelines but in two separate locations we had charting challenges as I mentioned before with the regulatory we followed

the same exact template that they were using in the hospital with their electronic medical record and that was a problem so the required charting included blood transfusions vaccinations we had to do an screening for alcohol

and substance abuse and I didn't have any of the resources to deal with any of those I had knows no vaccinations to give people we certainly weren't giving them blood transfusions and I didn't have any kind of social worker involved

with the outpatient center who could deal with anyone who felt suicidal or who had a drinking problem and because it looked like it was required at the time we were trying to get them done which meant longer prep times and it was

taxing on the patients and staff so we had to amend that lesson number three

staffing is evolutionary so there we are this is how we started we're happy we're eager we're brand new we had a slow start so we only had a few

patients at a time and I don't think we had any idea of how challenging our staffing was going to become look at us you have no idea we started with three technologists five nurses and the two are SAS the text

would work out of the control area and into the procedure rooms and the nurses would work in the two prep rooms two procedure rooms in our six bed recovery room our original plan was to slowly transition the nursing staff out of the

prep area through the recovery area as the needs of the day changed I would work more as the team coordinator moving things along and addressing delays breaking staff etc the RS aides have already explained where to help move

patients seamlessly through the center and escorting patients and family assisting room turnover as our case volume and our services increase though our staffing became inadequate we gained a vascular surgery service

neuroradiology and neuro interventional all came to our site so we also lost two of our nurses to disability which left us in an extreme staffing deficit we needed to continue to be creative and innovative while maintaining an

incredible standard of care and adhering to strict safety guidelines with multiple high-cost projects we had a new hospital that was opening up with NYU Kimmel the hospital became more stringent and approving additional

staffing throughout the campuses and off sites for quite a while although that's turning around we just hired two more nurses

lesson number four was to expect the unexpected

so the unexpected challenges we faced neuroradiology requires a lot of specimen collection the vascular surgery patient population tended to be much sicker with mobility issues deficiencies and ADL's and multiple comorbidities the

vascular surgery team required more assistance in the procedure rooms and their patients required a higher level of care than we had anticipated

lesson five is it's good to know people the advantages are that we had many

opportunities for education due to our close relationship with the hospital we had existing workflows that we can model and modify to our site to suit our needs we had an experienced and dependable administrative staff who were

really willing to go above and beyond to help us reach our goals at the OSI and we had an established working relationship with other medical teams and staff at the Medical Center our small and contained environment

allows for maximum efficiency we can quickly control any variables that happen throughout the day minimal delay and wait times due to lack of impatient emergencies which is great for our outpatients they don't want to wait

around and the affiliation with the major academic Medical Center allows for collaboration preparing for emergencies so we have extensive staff training we have emergency action plans staff preparedness we keep ACLs cards in every

room hanging on the wall for easy access we also have them in the recovery room we have an airway model that one of our colleagues has created for us so that if someone is having some kind of an airway emergency there's a pathway to follow we

also have protamine reaction boxes for the vascular surgery patients they reverse their heparin every single time and we didn't want to have to break open a crash cart or go looking for medications so I created a couple

different tackle boxes for that and airway boxes source our safety track record so as you can see in just one year we have performed a lot of procedures we've had six calls to 911 for patient transfers none of them were

too life-threatening we have a very low threshold for calling so I think we had to angiograms who had developed hematomas that transferred we had two vasovagal episodes we had one patient who seemed to have gone into a rapid

arrhythmia of some kind during the initial puncture for a I believe it was a filter placement but it turned out it was probably a pre-existing condition so nothing too emergent but if we feel

like we need to move the patient we will there were also admits to the ER pre procedure so we had a couple of instances where patients showed up and they were just way too sick for us to see them but too sick to send home so we

had them transferred and then we had some cancellations due to extremely late arrivals and lack of optimisation so they were disregarding the pre-op instructions that we had given them so they had eaten or their they had taken

their their medication for diabetes or they took their anticoagulants or something like that

so what does the future hold for us we would like to do more complex procedures right now we're doing why 90s after all

we built a hot lab we have radiation safety who's coming to our site on Mondays nuke med is also involved with that we've done for successful procedures so far so that was a big win for us we're also doing prostate artery

embolization which is new for our Center too which is also great we want to do anything that's safe and profitable essentially and we don't also maybe consider publishing our safety data to increase the available public data and

hope for better reimbursement rates so that was us a year in after everything that we had endured were still smiling we have a good time together I think they might kill me if they knew this picture was in my presentation so those

who know them please don't tell them but yeah we're still enjoying it there and that concludes my presentation

you have a question no so we don't have a lab on site we have a courier service that will take our specimens to the

hospital so for our biopsies for surgical pathology hematopathologist up three times a day which initially they said they would come once a day and then anything we have left over put it in the box outside the procedural room or the

procedure suite I guess they would come and pick it up well we were not comfortable with that I mean these patients are waiting for diagnosis so we had them amend that and pick up three times a day the last pickup happening

before the last nurse leaves the building so we could send bloodwork and we send CSF samples out for the lumbar punctures but we don't have a lab on site the only testing we do is blood Sugar's and urine pregnancy yes

we have it all set we have a whole pathway for the refers to fill-out based on what their request is so our nurse practitioners and our schedulers work with them to get all the proper paperwork loaded in it's pretty seamless

at this point yeah no no I haven't so no and actually what I've heard from the physicians in my specific department is that they really enjoy it because we're extremely efficient so that made me feel really

good yeah it's a good question so the refers we'll have a request come in the nurse practitioners will look at it and then we have a physician who will look at the imaging and determine where it is most appropriate I think the nurse

practitioners have a lot of leeway in making those decisions if it's clear some of the biopsies depending on how small they are might need cat scan guidance so that would change things a bit since we don't have a cat scanner

and our renal biopsies are hard now mm-hmm we're not we're not using co2 at our Center so if they had a severe contrast allergy they probably would not be a candidate for our Center yeah we use

I've s we have Ibis two but we're not using co2 I know they've used it at the hospital I don't know how frequently they're using co2 there no not that frequent no I'm not involved in that piece of it

at all usually that's worked out in advance of scheduling the patients or our schedulers usually work on that yeah so no CT we have to fluoroscopy rooms and we have ultrasound that we would use in the procedure room mm-hmm

yeah did you have another question yes yes and that's exactly right that's that's why we wanted to create this outpatient center and it's twofold we could take a lot of our small outpatient procedures and put them somewhere else

with the capability of maybe doing more procedures in one day but we wanted to give them the full experience we really wanted to make them feel like VIPs when they come into the center nobody likes to come and wait nobody likes to be told

that there's an emergency no one cares when you're there and you're waiting to have a biopsy that can determine whether you need to have chemotherapy or not you really don't care so it's nice to have a place where we can keep things on

schedule and keep people feeling comforted and really taken care of so we've gotten really good feedback from our patients they do all the outpatients scheduling so there are some outpatients that go to the hospital as well so they

they take care of all of that in their office which is off-site it varies so on a day where we might not have an additional service we maybe see about 10 patients and that number can go up if we're running two rooms it can go

up to about 15 we scheduled it for early afternoon to allow for recovery time so I have nursing staff there at 7 a.m. and the last nurse leaves at 6 p.m. we have staggered staffing right now there is one two three four seven nurses six

nurses and I'm the seventh nurse yeah hmm every day yeah we're five days a week mm-hmm yes we do rotate so we create a weekly schedule and it's just a whiteboard I have two whiteboards one in the nursing station in recovery and I

have one in the control area so everyone can see it easily and it just rotates through so if you're in the procedure room one week the next week you'll be in prep recovery and then the next week you'll be in procedure room too and then

you'll be in prep recovery and it just keeps going that way so that you're not stuck in prep and recovery for a few weeks at a time because it's taxing yes yes we're two blocks away we are affiliated with other hospitals

but I haven't had that happen yet I don't yeah I don't know that it would be an issue yeah any other questions yes yes so sometimes if it's one service if it's just interventional radiology we stagger it because it's one physician so

when they're finishing up in procedure room one we have the patient in procedure room two being prepped and ready to go so the doctor can come right in we can do our time out and begin when there's two services they run

independently well we have quad-a comes we had them come for the initial visit do you mean oh no I don't think so in the last year that we've been open no I don't think so

sure yeah why not yep yes yes yeah yes oh that's a good question too we don't have Pyxis we don't have locked on these cells so

we maintain all the supplies ourselves I order all the medications and then we have to narcotic lockers I guess you can call them with keypad entry and then we do a 24-hour count I don't know if those of you who remember the times before

Pyxis when you had the big workbooks and you had to count it and write it out and everything that's what we're doing but we only have to do it every 24 hours while this Center is open so I don't have to be responsible for them on the

weekends or on holidays yeah yep yeah so everything we follow all the electronic charting but then for the narcotic logs yes it's all written in there some of them are and they're locked in a cabinet right and then I have a supply

in recovery that is all organized I keep a spreadsheet at night order every month it's very complicated and you need to set up an entire like data system for it run cables and so and for the amount of medications we use we use you know the

same medications just a small type of medication over and over again it would be a very large system for a small amount of medication anything else oh that's great yeah that's that's

really nice to have there there are times where there's shortages knowing who your rep is is good and then you can kind of work things out so when you're used to having certain concentrations of medication certain amounts maybe you

want to use a multi-dose vial versus single dose vials sometimes you just can't get that it's on backorder so working with your rep and saying this is what I want what can you give me that's most like this and that's that's what

I've done but every once in a while something is on back order across the board there is no lidocaine it's on its shortage so I just try to order a lot in advance and then reorder every month so that I always keep access as well

Yesi we're not linked to the pharmacy at the hospital so we're independent we have to we have to find them I don't know if I can really answer that question I believe there's a few different reps from different companies

but I'm not directly involved with them they're not in our procedure rooms vascular surgery does have reps that come on-site frequently but they're not allowed to assist in the procedure anyway those are quad-a rules so we do

have support from reps but I'm not sure how many vendors we work with or you know thanks Emmy she all right thank you everyone [Applause]

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