Operations

 Procedures Service Core Team

• Dr. Orpheus Kolokythas (primary point person) and Dr. Bill Warren
• Gil Camero, Procedures Service and Ultrasound Coordinator

Associated Point People

• Andrea Miller - BI/Neuro reading room front desk
• Maricris Sison - BI/Neuro reading room front desk
• Mario Ramos - CT Supervisor, and team
• Joseph Ancheta - Nurse Manager, and team

Workflow

This checklist should serve as a quick guide to help you streamline your rotation.  The rotation will be shared with an R3 or R4 resident.

The goal of this rotation is to:

1. Increase your skills in BI procedures
2. Provide the institution with a professional and responsive Body Imaging Procedure Service
3. Provide our section with a solid database for tracking, QA, and academic purposes

Recommended list of Readings:

1. This checklist
2. PS operations (document for goals and operations of this service)
3. Patient prep document for patient related details around the procedure
4. Selected articles with regard to Body Imaging interventions
   

Workflow

On arrival to the service

Check for changes in the status of the days procedures

Check the status of staffing for the day and plan accordingly.

2 hours before the procedure:

Verify status of the patients blood work, expedite execution of blood draw on the floor.

Order vials for injections / nerve blocks if needed (Ethanol, Kenalog)

1 hour before the procedure:

Coordinate with Gil (for US guided procedures), or CT techs to guarantee timely arrival of the patient in Radiology department (initiate call to 4S to call the patient to radiology 60 minutes before the procedure starts). Also synchronize arrival with radiology nurses' availability.

Consent the patient and perform the physical, preferably in the nurses' area or in one of the prep bays, although it can also be done in the US room (not in the CT room). Check for results of blood work and for clinical procedure eligibility (fever, restlessness, anxiety, nausea etc.)

Attire:  Although not mandatory, scrubs are advised on this rotation.  Badge is mandatory!

The procedure:

US:

• Discuss the approach with the sonographer away from the patient on PACS
• Scan the patient with sonographer to verify sonographic eligibility
• Determine acoustic window and route for approach

CT:

• Verify correct position of the patient on the table, make sure biopsy device will fit through the gantry and place patient eccentrically on the table if needed.
• Place marking grid on the patient before the scan
• Determine scanning parameters and instruct CT tech about scanning protocol (low dose, where applicable)

All procedures:

• Verify presence of requested sample containers (formalin, RPMI, sterile container?).
• Verify presence of chest drain in the scanning room before chest biopsy begins.
• Set up the procedure table (with tech support).
• Discuss positioning and other main points with the nurse, fill out orders
  
• Initiate verification process. (Important! We don't want to do the wrong procedure on the wrong patient.) Call the attending, and perform the procedure.
• For lung biopsies:  Order administration for first dose of conscious sedation before first scan (differences in breathing after sedation may jeopardize access route when planned based on CT before sedation!).
• Complete QA checklist in the room before scrubbing in.
  

After the procedure:

• Fill out pertinent forms:  physician orders, progress note, documents for samples, etc.
• Final check for complications.
• Give patient instructions for post procedure care.
• Document the procedure in the radiology report (use standardized reporting macros).
• Make sure the patient has received the fellows' evaluation form with your name on it.
  

At the end of the day:

Check with the nurse on 4S for complications, if necessary.  Even though not mandatory, it is always a gesture of care and reflects professionalism to perform a pre-discharge visit on the outpatient floor.

Check status for next days procedures and verify arrangements for labs, FFP, albumin, outside images, etc. (before Gil leaves, usually at 4:00pm)

Enter all procedures in database (semi-automated via IT) omit editing procedures involving fluid collections, unless there was a complication.

• Note: The database is the only tracking tool for your final certificate, we will not be able to list your number and types of procedures at the end of the fellowship unless you fill out the database completely as required.

• Also: Maintenance of the database is one core criterion in your monthly evaluation. Tracking clinical and histopathological results of a procedure and taking appropriate actions reflects the quality of the service.

At the end of the rotation:

Complete omitted or previously pending histopathology results in the database.

Fill in your successor in the operations of the service.

Show your successor how to access and manage the database.

Log and summarize the procedures you performed using the database and forward the results to the directors of the fellowship program and the procedure service.

In case of a complication:

• Discuss the situation with the patient
• Notify the nurse on the outpatient floor 4S
• Contact the referring physician or designate for a consultation.  If this person is unavailable
  • during normal working hours: Initiate a Medicine Consult
  • after normal working hours: Page the admitting Medicine R3 resident on call.
• If a chest drain/tube placement is (or will likely become) necessary, a CT surgery consult should follow, and IR should be informed.

Following up Results of Procedures

This is one of the most important components of the rotation, since this is where we can:

1. validate our imaging reports and get feedback for our proposed diagnosis
2. make a difference for the patient by communicating clinically relevant discrepancies between imaging and histology results to the clinical provider (true positive vs. false negative results!)
3. detect delayed complications and learn about treatment and outcomes of complications
   

• Look up results pending from prior procedures on a daily basis, and document the results in the database. Important:  Rate results in the database according to their plausibility (consistency test, "Histology true positive?" column in the database).
• It is of paramount importance to notify the referring colleague immediately if you believe the histologic diagnosis could be a false negative result!
• Follow up all patients for complications (checking clinical notes or radiology reports soon -- a few days -- after the procedure, or earlier, if complication occurred during the procedure) and document this result in the database.