2
20
773
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a2e430404ef570db3134f1f9f52cf731
PDF Text
Text
A Review of Intravenous Blood-Sparing Systems and Techniques in Use
Among NIH Harvard Catalyst Clinical Research Centers (HCCRC):
Beth Israel Deaconess Medical Center, Brigham & Women’s Hospital,
and Massachusetts’s General Hospital
Audrey Nathanson, RN, BSN1; Mona Lauture, RN, BSN1; Tracy Cragin, RN, BSN2; Catherine Griffith, RN, PhD3; Sharon Maginnis RN, BSN3
Purpose
Beth Israel Deaconess Medical Center
Brigham & Women’s Hospital
Open system
Open x 2 per blood draw
No discard
No IV pump
No heparin
Cost = $0.84
Background
• IV blood sparing systems have been standard practice for studies
requiring frequent blood sampling for many years.
• Nurses at one center identified practice ambiguities and began to
question their blood sparing practices.
• A general consensus developed related to the need for a system
evaluation.
• Through the HCCRC Nursing Best Practice Committee a practice
question was formulated: is there an IV blood sparing system better
suited to improving nursing practice, sample integrity and research
participant satisfaction?
Open system
Open x 1 per blood draw
No discard
IV pump
Heparinized
Cost = $6.18
Closed system
No discard
No IV pump
No heparin
Cost = $16.99
• To review blood sparing systems and techniques in use among the
HCCRCs as a first step in determining best practices.
Massachusetts’s General Hospital
Open system
Open x 1 per blood draw
No discard
IV pump
No heparin
Cost = $6-7.00
Open system
Open x 3 per blood draw
0.2mL discard
IV pump
No heparin
Cost = $0.82
Open or Closed Systems refers to whether in the process of obtaining a blood
sample the system is open to air or not.
Cost excludes syringes, IV tubing, extension sets, intravenous fluids.
Method
Summary of Staff Interviews
• The HCCRC Nursing Best Practice Committee, membership
representing BIDMC, BWH, MGH and BCH, discussed pros and
cons of their respective blood-sparing systems.
• Metrics were identified: patient safety, comfort, sample integrity,
ease of use and cost.
• An extensive literature review was initiated and has continued to
date.
• Nurses at each center were interviewed about their thoughts on
the pros and cons of their systems and techniques. Quotes from
the interviews appear in the table to the bottom right.
Top Concerns
Fibrin formation-clots
• The group discovered that each institution had its own IV blood–
sparing system and techniques.
• All nurses expressed comfort with their system and techniques.
• Nurses admitted to the practice of continued use of systems
because of habit and familiarity. Most nurses did not know how the
blood sparing system came to be used on their unit.
• Through interviews, nurses voiced their concerns.
• Each CRC found areas for improvement and made
recommendations.
• None of the institutions had ever initiated system updates to reflect
new technology.
Change to any system that would ↓fibrin formation
↓risk of blood exposure ↓infection risk
Open System → increased risk of infection
Change to a closed system
Open System → Blood Exposure → Increased staff risk
Evaluation
Top Recommendations
Shorten extension tubing length
Sample of Staff Nurse Comments
CONCERNS
• It’s not truly a closed system; too many connections needed to put the system together which can result in loose connections – leaks, bacteria, etc.
• I strongly dislike the [open] system because there’s too much opening and closing, high risk for infection, high risk for injection of air, etc. I also do not think it is as efficient a system. There is a much smaller volume that is used for the [closed] system.
• [I have concerns about the ] length of tubing to patient. Too long and puts too much stress on the vein. System encourages fibrin formation.
• I would prefer that we were able to use claves [needleless connectors] on the ports. I feel like there is a high risk for us to have blood exposure, so I would like the system to be a little tighter…
RECOMMENDATIONS
• [I would recommend a change to] a system that has less connections.
• [I would recommend we] shorten the tubing to the patient and decrease any connections not needed to prevent clot formation.
• Something that alleviates the open system, clotting, and all of the above.
• I think there needs to be more standardization across everyone who uses the systems. As far as, are we vacutaining, syringing, capping, leaving syringes on, etc.
• I would just recommend we eliminate the [open] system and go the [closed] system.
• I think that there are some studies that use a 0.2mL clear of the proximal [sample] port. And I think that should be a universal system for all studies to resolve some of the issues that you asked about earlier.
• I like the [closed] system. If we could change over to the [closed] system, that’s what I would do. It is cleaner, self-enclosed, there is less room for error.
Next Steps
•
•
•
•
•
Complete literature review: determine if further investigation is needed
Continue to research new technologies that will address stated concerns and recommendations
Report any evidence for practice changes to Best Practice committee
Best practice committee to determine if a change in practice is recommended and report to their respective sites
Individual HCCRCs can decide if a change in their practice is warranted or preferred
Acknowledgements
The authors gratefully acknowledge the support of the staff at each Harvard Catalyst
Clinical Research Center, Sheila Driscoll, MSN at BWH, Linda Godfrey- Bailey, MSN, ACNS,
BC at BIDMC, Kathy Hall, MS, RNCS, ANP-BC, and Dan David, RN, BSN, PhDc at BIDMC.
This work was conducted with support from Harvard Catalyst | The Harvard Clinical and
Translational Science Center (National Center for Research Resources and the National
Center for Advancing Translational Sciences, National Institutes of Health Award UL1
TR001102) and financial contributions from Harvard University and its affiliated academic
healthcare centers. The content is solely the responsibility of the authors and does not
necessarily represent the official views of Harvard Catalyst, Harvard University and its
affiliated academic healthcare centers, or the National Institutes of Health.
�
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Title
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Silverman Symposium
Description
An account of the resource
Each year the Silverman Symposium poster session offers BIDMC staff and affiliates the opportunity to share experiences and learn about efforts to improve Quality and Safety.
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Silverman Poster
Primary Contact
If you would like more information about this project, contact this person. Make email address clickable.
Audrey Nathanson (<a href="mailto:anathans@bidmc.harvard.edu">anathans@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Nursing
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Audrey Nathanson
Mona Lauture
Tracy Cragin
Catherine Griffith
Sharon Maginnis
Dublin Core
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Title
A name given to the resource
A Review of Intravenous Blood-Sparing Systems and Techniques in Use among NIH Harvard Catalyst Clinical Research Centers (HCCRC): Beth Israel Deaconess Medical Center, Brigham & Women’s Hospital, and Massachusetts’s General Hospital
Date
A point or period of time associated with an event in the lifecycle of the resource
2015
Format
The file format, physical medium, or dimensions of the resource
pdf
Effectiveness
Efficiency
Patient and Family-Centeredness
Safety
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9a7c9d8ebaf167214535fcd90bc2a0b6
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Text
A Team-Based Approach to Maintaining a Successful 340B Program
Julie F. Lanza CPhT CSPT, Parth Patel BSN RN, Shawn Wood CPhT 340B ACE, Denise Young CPhT, May Adra PharmD
TAP TO GO
BACK TO
KIOSK MENU
The Interventions
Introduction/Problem
Create internal application to audit prescriptions for 340B eligibility.
The 340B Drug Discount Program is a US federal government program created in 1992 that requires
drug manufacturers to provide outpatient drugs to eligible health care organizations and covered
entities at significantly reduced prices.
BIDMC is a Disproportionate Share Hospital (DSH) that participates in the 340B program. DSH serve
a significantly disproportionate number of low income patients.
Compliance and Integrity is crucial given the complexity of the 340B program. 340B Drug Pricing
Program covered entities must ensure program integrity and maintain accurate records documenting
compliance with all 340B Program requirements. Covered entities are subject to audit by
manufacturers or the federal government. Covered entities will be audited for all 340B program
requirements. Covered entities are subject to audit by the manufacturer or the federal government.
Develop a workflow with everyday processes to share and maintain auditable records for any/all
audits that may occur.
Created workflow processes to review 100% prescriptions for 340B eligibility on the contract
pharmacy side and a percentage of all dispensations from the split billing group.
A Third Party Administrator (TPA) is contracted to determine eligibility based on a set of rules
provided. BIDMC developed an algorithm to electronically screen above and beyond what the TPA
was able to do, therefore adding a layer of adherence.
Develop a communication process for the team for day-to-day operations as well as audit
preparedness.
The three major arms of the 340B program are Contract Pharmacy, Compliance & Split Billing.
Results/Progress to Date
Created a restricted auditable records folder accessible only to members of the 340B team.
Aim/Goal
Our aim is to create an internal 340B eligibility process while working with key stakeholders to audit
outpatient prescriptions and a percentage of mixed-use dispensations to maintain compliance with the
340B program.
The goal was to create a process by which all three arms of the 340B program work cohesively as a
team in collaboration with a multidisciplinary group of leadership from across the medical center.
Any documentation related to eligibility, registration and drug purchases of/by the, Covered entity,
Child sites or contract pharmacies must be maintained for auditing purposes.
Contract to
provide services
Policies & Procedures
regarding procurement
The Team
340B Executive Steering Committee – Mike Cullen, Tom Siepka, Chirag Desai, George Ogin, Jamie
Katz, Sam Skura, May Adra
340B Contract Pharmacy Team - Nary Heng, Sonia Najdzien, Chirag Patel, Erika Perry, Juan Rivera,
Denise Young
340B Split Billing Team – Shawn Wood, Jonathan Dacey
340B Data Analytics – Parth Patel
Pharmacy Compliance - Julie Lanza
Accounts
Medicare
Cost Report
Contract pharmacy
agreements
Purchasing records
(340B & non-340B)
Types of auditable records that are readily retrievable
For more information, contact:
Julie Lanza, CPhT, CSPT (jlanza@bidmcharvard.edu)
�A Team-Based Approach to Maintaining a Successful 340B Program
Julie F. Lanza CPhT CSPT, Parth Patel BSN RN, Shawn Wood CPhT 340B ACE, Denise Young CPhT, May Adra PharmD
More Results/Progress to Date
340B Split Billing Team
Audits from Split Billing Areas
2018
2017
10 Team
Members
12 Team
Members
Algorithms
Policies & Procedures
Invoicing
Auditing of contract
Pharmacies
Auditing of contract
pharmacies
Contract Review
2019
Auditing 214 Contract
Pharmacies
340B Savings Optimization
340B Team
Expansion
340B Contract
Pharmacy Team
Contract Review
6 Team
Members
340B Data Analytics
QA Dashboard
340B Compliance
Self-auditing of program
Team Composition & Responsibilities
Lessons Learned
Split
Billing
27
Contract
Pharmacy
16
Communication is imperative is maintaining a successful program. With the development of Quarterly
Executive Steering Committee meetings, monthly 340B Operations meeting & weekly calls with each group,
we have learned to implement changed based on team member feedback
Awareness of future expansion business expansion plans is important for planning.
Next Steps
85
Develop a Medical Center wide education plan as all involved in patient care on a direct or indirect level
are an integral part of compliance. Keeping every member of the patient care team educated about the
340B program is crucial in maintaining compliance.
Expand the 340B team in alignment with the expansion of pharmacy services and Beth Israel Lahey
Health
273
Areas for Improvement
No Findings
Areas for Improvement
Results from most recent external 340b Program Audit
No Findings
For more information, contact:
Julie Lanza, CPhT, CSPT (jlanza@bidmc.harvard.edu)
�
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Title
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Silverman Symposium
Description
An account of the resource
Each year the Silverman Symposium poster session offers BIDMC staff and affiliates the opportunity to share experiences and learn about efforts to improve Quality and Safety.
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Silverman Poster
Primary Contact
If you would like more information about this project, contact this person. Make email address clickable.
Julie Lanza (<a href="mailto:jlanza@bidmc.harvard.edu" target="_blank" rel="noreferrer noopener">jlanza@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Pharmacy
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Mike Cullen
Tom Siepka
Chirag Desai
George Ogin
Jamie Katz
Sam Skura
May Adra
Nary Heng
Sonia Najdzien
Chirag Patel
Erika Perry
Juan Rivera
Denise Young
Shawn Wood
Jonathan Dacey
Parth Patel
Julie Lanza
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Title
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A Team Based Approach to Maintaining a Successful 340B Program
Date
A point or period of time associated with an event in the lifecycle of the resource
2019
Format
The file format, physical medium, or dimensions of the resource
pdf
Compliance
Efficiency
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0d5f573b21019737acf74c771f8d1c2a
PDF Text
Text
Access to Video Images of Swallowing & Voice in OMR
The Problem:
Lack of access via WebOMR to Videoswallow and Laryngeal Videostroboscopy
images made it difficult for attending physicians to read these exams in order to
provide a medical diagnosis. Referring doctors and PCP’s only had access to written
reports and were unable to view these images stored within workstations that were
not integrated into PACS or Centricity Web.
Lessons Learned, continued
Aim/Goal
The Results/Progress to Date
1.
2.
3.
To integrate digital video images of swallowing evaluations and vocal fold
examinations into PACS for viewing by referring physicians and PCP’s.
To improve the workflow for Attending Radiologists and Otolaryngologists
when reading these examinations to provide a medical diagnosis.
To improve patient and family education about swallowing disorders
The Team
Coordination of Care is Improved and Workflow is Streamlined by making
Video images available via WebOMR
To Access Video Swallow clip:
Step 1: Log into OMR
To Access Vocal Fold Clip for Voice patients:
Step 2: Select Patient
Step 3: Click on Reports Tab
Step 4: Click on “Images” located between “Radiology” and “Other Reports”
Step 5: New window will open “Centricity Enterprise” viewer.
Choose from
work list per
study date
(pre and
post-op)
Step 5: Then, Click on Hyper link
Note: “ES” under
Modality (Mod)
refers to Strobe
The Interventions
Presented Proposal to Enterprise PACS committee
Purchased DICOM Modules for Each Swallowing & Voice Workstation
Used Grant Funds to Upgrade Workstations
Coordinated with Radiology PACS & Enterprise PACS to upload and store
Video clips of Swallowing Ability and Voice Production, and to Provide Access
to these images in Web OMR
Step 2: Select Patient
Step 3: Click on Reports Tab
Step 4: Choose a Radiology / VIDEO OROPHARYNGEAL SWA report
on specific date of service
The Enterprise PACS Team – Sue Rathbone, Phil Purvis & Lenny Markowitz
Cynthia Wise Wagner, MS, CCC-SLP and members of the Voice, Speech &
Swallowing Service
Step 1: Log into OMR
Step 6: Play selected Video Clips by clicking on navigation panel on left.
Click here
for clips
Step 6: View still images and video of vocal folds by clicking on list on the left.
Click
here for
clips
and
images
Lessons Learned
SLP’s report with summary and recommendations is located in the Notes
section which can not include any still or moving images or hyperlinks
Vocal Fold Image Data in Enterprise PACS is “pushed,” creating the
possibility of user error in data entry which might result in images not
showing in Centricity Web via WebOMR
Vocal Fold Image labeling is not available, so identification of image type
is unclear.
Videoswallow Image Data in Radiology PACS is “pulled” from the clip #
for accurate patient / exam mapping
Small Selected Video Segments & Still images can be stored in Radiology
PACS due to large file sizes; Not the entire exam
Next Steps/What Should Happen Next
Inform referring physicians and PCP’s about high quality image availability
Educate physicians about the location for viewing these images to achieve
meaningful use of the electronic medical record
“Pull” data for strobes to reduce potential for data entry errors
Improve labeling of stroboscopy images for ease of identification
For More Information Contact
Cynthia Wise Wagner, MS, CCC-SLP,
Manager, Voice Speech & Swallowing Service,
(617)632-7404; cwagner@bidmc.harvard.edu
�
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Title
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Silverman Symposium
Description
An account of the resource
Each year the Silverman Symposium poster session offers BIDMC staff and affiliates the opportunity to share experiences and learn about efforts to improve Quality and Safety.
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Silverman Poster
Primary Contact
If you would like more information about this project, contact this person. Make email address clickable.
Cynthia Wagner (<a href="mailto:cwagner@bidmc.harvard.edu">cwagner@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Patient Care Services
Voice Speech and Swallowing
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Sue Rathbone
Phil Purvis
Lenny Markowitz
Cynthia Wise Wagner
Members of the Voice, Speech and Swallowing Service
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Title
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Access to Video Images of Swallowing and Voice in OMR
Date
A point or period of time associated with an event in the lifecycle of the resource
2012
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pdf
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ee300087cb6f037947b12bf96e845d91
PDF Text
Text
Accuracy of Doppler Ultrasound for Covered TIPS
The Problem
The Results/Progress to Date
Transjugular Intrahepatic Portosystemic Shunts (TIPS) have provided a life
altering and life-saving treatment for patients with symptomatic portal
hypertension.
TIPS were first placed with uncovered metal stents, which had high rates of
stenosis and occlusion leading to practice of routine ultrasound screening for
TIPS malfunction.
TIPS are now placed with polytetrafluoroethylene (PTFE) covered stents that
have significantly higher patency rates compared to uncovered TIPS.
Ultrasound criteria for TIPS evaluation are based on data from uncovered
TIPS.
The accuracy and need of ultrasound surveillance for covered TIPS have been
questioned.
As an academic and liver transplant center, BIDMC cares for a large
population of patients with end stage liver disease (ESLD) and portal
hypertension.
Studying the accuracy of ultrasound in examining for covered TIPS
malfunction will assess what role, if any, ultrasound plays in covered TIPS
evaluation.
Such knowledge will lead to more effective care for TIPS patients as well as
efficient use of resources.
Aim/Goal
The goal of our study was to assess the predictive value and accuracy of Doppler
ultrasound in the evaluation of covered TIPS, to evaluate the role of Doppler
ultrasound in covered TIPS management, and to characterize factors contributing to
inaccuracy of TIPS ultrasound in evaluating covered TIPS patency.
The Team
Specificity
Accuracy
False
Positive
False
Negative
85%
98%
97%
6
5
Covered TIPS
malfunctions
Patients who underwent TIPS revision or venography from 1/1/200512/31/2013 and who had TIPS placed at BIDMC and were evaluated by
ultrasound were reviewed.
Ultrasound results were compared with venography for accuracy regarding
TIPS patency, stenosis, and occlusion.
Asymptomatic Covered TIPS
malfunctions
34
16 (47%)
5 of 16 occluded at venography
Lessons Learned
We found ultrasound to be an accurate method to evaluate for covered TIPS
malfunction.
We also found surveillance of covered TIPS in asymptomatic patients has a role in
patient management due to the discovery of malfunctioning covered TIPS in
asymptomatic patients.
Review of the false positive and false negative ultrasound examinations has provided
valuable sources of improvement in examination performance and examination
interpretation.
Next Steps/What Should Happen Next
Ultrasound Division – Department of Radiology
Interventional Radiology
The Interventions
Covered TIPS Ultrasound for TIPS Malfunction (n=360)
Sensitivity
Review the small number of false positive and false negative ultrasound
examinations with sonographers and radiologists to attempt to decrease
the small number of false positive and false negative ultrasound
examinations.
Ultrasound data should be further analyzed to evaluate if optimal criteria
for covered TIPS malfunction differ from previously published uncovered
TIPS data.
Findings to be published in the scientific literature to advance covered
TIPS evaluation.
For more information, contact:
Thomas Keimig, M.D, Abdominal Imaging Fellow
tkeimig@bidmc.harvard.edu
�
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Title
A name given to the resource
Silverman Symposium
Description
An account of the resource
Each year the Silverman Symposium poster session offers BIDMC staff and affiliates the opportunity to share experiences and learn about efforts to improve Quality and Safety.
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Silverman Poster
Primary Contact
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Thomas Keimig (<a href="mailto:tkeimig@bidmc.harvard.edu">tkeimig@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Radiology
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Ultrasound Division – Department of Radiology <br />Interventional Radiology
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Title
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Accuracy of Doppler Ultrasound for Covered TIPS
Date
A point or period of time associated with an event in the lifecycle of the resource
2015
Format
The file format, physical medium, or dimensions of the resource
pdf
Effectiveness
Efficiency
-
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cd59f57bdfdfebe3f215bc4549b0e620
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Beth Israel Deaconess Hospital-Milton
Achieve Leading Practice Designation in Operating Room Turnover Times
The Problem
The Results/Progress to Date
In May 2013, an onsite audit was performed by an external vendor specific to
peri-operative services at Beth Israel Deaconess Hospital-Milton. The objective
of this internal audit was to review the hospital’s Operating Room (OR)
scheduling process and staffing, as well as to evaluate opportunities to enhance
OR efficiency and utilization. The measurement period for this audit was from
April 2012 through March 2013.
LOWER IS
BETTER
Audit
completed
Interventions
implemented
From this audit, one of the opportunities for improvement identified related to
the timeliness of OR turnover between operative cases. The established industry
standard for this process is <25 minutes, however the actual time for BID-Milton
was 43 minutes.
G
O
L
Aim/Goal
Reduce OR Room turnover time between surgical cases to achieve leading
practice goals, i.e., 20-25 minutes for inpatient surgeries.
The Team
OR Staff
Environmental Services
Department of Anesthesia
Department of Surgery
Lessons Learned
The Interventions (Select Actions Taken)
Reviewed AORN recommended practices on room cleaning to expedite
room turnover and terminal cleaning of ORs – no opportunities identified
Considered eliminating the OR RN in the patient transport process from
the PACU – could not be implemented
Allowed for patient early entry into the operating room (prior to completion
of room setup) to maximize effects of parallel processing (LEAN – optimize
‘External Setup’)
Led by a new Interim Director of Surgical Services in November of 2013,
performance expectations set with staff as a means to modify historical
behavior/practices
Staff held accountable for performance – times tracked and shared with
staff – overall, by OR room and by responsible individual staff member
OR Manager performed daily rounds
Worked collaboratively with Anesthesia at start-of-day “flow” meeting
Engagement and education of CSR staff on their role in OR flow
Decreased OR room turnover times allowed for daily “add-on” cases to be scheduled
during normal OR hours – i.e., decreased incidence of OR day being extended beyond
normal close time (decreased use of overtime)
Accountability and data transparency drove changes required to improve OR
utilization and efficiency
Next Steps/What Should Happen Next
Celebrate leading practice achievement in room turnover time with staff
Continue with interventions and monitor ongoing success relative to goals
Build on this success through other in-progress PI initiatives to address additional
opportunities identified as part of audit, e.g., first case start times, block booking,
OR room utilization etc.
For More Information Please Contact: Alex Campbell, MSN, RN, NE-BC, CPHQ, Director HCQ & PS
alex_campbell@miltonhospital.org
�
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Title
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Silverman Symposium
Description
An account of the resource
Each year the Silverman Symposium poster session offers BIDMC staff and affiliates the opportunity to share experiences and learn about efforts to improve Quality and Safety.
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Silverman Poster
Primary Contact
If you would like more information about this project, contact this person. Make email address clickable.
Alex Campbell (<a href="mailto:alex_campbell@miltonhospital.org">alex_campbell@miltonhospital.org</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Operating Room Staff
Medical Staff
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BID-Milton
Project Team
Operating Room Staff
Environmental Services
Department of Anesthesia
Department of Surgery
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Title
A name given to the resource
Achieve Leading Practice Designation in Operating Room Turnover Times
Date
A point or period of time associated with an event in the lifecycle of the resource
2014
Format
The file format, physical medium, or dimensions of the resource
pdf
Efficiency
Timeliness
-
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1c3c7cc97a498b77f22ed1b30daa2b21
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Achieving Reliability in Histology
Edward J Yoon MD1, Benjamin Edwards1, Shaelyn Casey1, Michael Hallett1, David Bowman HT ASCP1,
Sergey M Pyatibrat MD1, Yigu Chen MPH1, Jeffrey D Goldsmith MD1, Yael K Heher MD MPH1, Kenneth E. Sands MD MPH2
1. Beth Israel Deaconess Medical Center, Harvard Medical School, Department of Pathology 2.Beth Israel Deaconess Medical Center, Harvard Medical School, Department of Healthcare Quality, Boston, MA.
BACKGROUND
COLLECTED DATA
SINGLE-PIECE WORKFLOW SOLUTION – iFREEZE
Despite widespread efforts to abate labeling errors within the surgical pathology
laboratory, incidence specifics have not been rigorously studied and standardized
improvement efforts have not been reported. Specimen misidentification in the
histology laboratory can result in serious patient harm. By utilizing tools such as
root cause analysis, process mapping, selected quality metric assessment, and
targeted quality improvement initiatives, we were able to drastically reduce
labeling error and improve reliability in the labeling process.
Prior to interventions:
Paraffin blocks are kept physically
separate from their corresponding
glass slides at the microtome,
increasing the chances of specimen
mix-ups at this step. In addition,
already difficult to visualize
accession numbers are backwards
and upside down.
OBJECTIVES
To reduce labeling errors using QI tools such as Plan-Do-Study-Act and Lean.
METHODS
Two distinct error-prone steps were identified in the laboratory workflow: manual
slide printing and microtome cutting. Frontline staff and QI leadership created
targeted workflow redesigns aimed at the vulnerable steps. In the initial PDSA
cycle, bar-code technology was rolled out at the slide printing step. The second
PDSA cycle used concepts such as Lean and single piece workflow to drastically
cut specimen mix-ups at the microtome.
Innovative Framework to Engage
and Effect Zero Errors (iFreeze):
Info-Graphic Credit: Yigu Chen MPH CSSGB
PROJECT IMPETUS
RESULTS
This single-piece workflow device
drastically reduces the potential
for specimen mix-ups by reuniting
matching blocks and slides and by
improving practical visualization
of accession numbers.
147, 455 cases were analyzed during the study period. The baseline error rate
was captured at 1% (793 errors in 76,958). Following PDSA cycle #1, the
error rate dropped to 0.3% (92 errors in 32,534), and after PDSA cycle #2, the
labeling error rate now stands at 0.2% (78 errors/37,963 cases). Overall, an
80% reduction in error rate has been noted. In addition, error data became
more reliable with less special cause variation and an improved moving range.
CONCLUSIONS & FUTURE DIRECTIONS
Info-Graphic Credit: Yigu Chen MPH CSSGB
Following PDSA cycles 1 and 2, quality improved on multiple levels. First, we
approached our goal of 0% labeling errors, as shown in the control chart. The
process itself also became more reliable, with errors occurring at a predictable rate
and falling within usual cause variation, as opposed to special cause variation.
This is shown by the decreased outlying data points in the control chart as well as
the decreased moving range, both indicating improved reliability of the process.
Histology labeling errors are prevalent and can lead to significant patient
harm. We were able to implement concrete targeted QI measures that
dramatically decreased our overall error rate, improved process reliability, and
made care safer for patients utilizing our services.
Future directions will necessarily include the continued collection and
analysis of error-related data in order to assure that error rates remain at an
absolute minimum.
�
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Silverman Symposium
Description
An account of the resource
Each year the Silverman Symposium poster session offers BIDMC staff and affiliates the opportunity to share experiences and learn about efforts to improve Quality and Safety.
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Silverman Poster
Primary Contact
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Edward Yoon (<a href="mailto:eyoon@bidmc.harvard.edu">eyoon@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Pathology
Health Care Quality and Safety
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Edward J Yoon<br />Benjamin Edwards<br />Shaelyn Casey<br />Michael Hallett<br />David Bowman<br />Sergey M Pyatibrat<br />Yigu Chen<br />Jeffrey D Goldsmith<br />Yael K Heher<br />Kenneth E. Sands
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Title
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Achieving Reliability in Histology
Date
A point or period of time associated with an event in the lifecycle of the resource
2015
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The file format, physical medium, or dimensions of the resource
pdf
Effectiveness
Efficiency
Safety
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6621e9089de2e16cd656d356efe1c4b6
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ACMS Stable Patient Extended INR Protocol as a model for reviewing, assessing, and
implementing new clinical guidelines into patient care practices.
men
Jennifer E. Mackey, PharmD; Lynde K. Lutzlow, Scot B. Sternberg, MS; Diane M. Brockmeyer, MD;
A teaching hospital of
Harvard Medical School
Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
Problem:
The 2012 update to the American College of Chest Physicians (ACCP) Guidelines included
a recommendation that patients with “consistently stable INR results” on warfarin may extend
the INR monitoring interval from the every 4 week standard to “up to 12 weeks.”1
Anticoagulation Management Service (ACMS) patient care practices must continually evolve
to incorporate updated evidence-based guidelines. A formalized process is necessary to
review, evaluate, and implement new procedures to reflect current recommendations.
Objectives:
Establish a model process for review of new clinical recommendations and patient care
protocols as they pertain to BIDMC Anticoagulation Management Service (ACMS) patients.
Create a protocol that incorporates updated INR testing frequency recommendations and
standardizes anticoagulation clinic practices.
Reduce patient INR testing burden while maintaining safe warfarin therapy.
Context and Intervention:
The BIDMC ACMS is composed of nurses, pharmacist, and a medical director who manage
warfarin care for about 800 patients with primary care doctors in a large academic care
practice.
ACMS established the below process for new evidence review to be utilized:
Identify new
published
practice
guideline
Review
primary
evidence
and expert
opinions
Draft new
patient care
protocol
Multidisciplinary
external review,
input, and
approval
Staff Training,
Pilot the protocol,
Assess staff
compliance
Assess outcomes
and revise
protocol
The updated ACCP Guideline INR frequency recommendation and supporting clinical
studies were critically evaluated by the ACMS team.
Review of primary data led to team assessment that the data for extending test interval
to 12 week INR checks are not robust. The team decided on a conservative approach
of maximum duration between INR tests of 6 weeks.
A Stable Patient Extended INR Testing Protocol was created.
Inclusion, exclusion/discharge criteria were defined:
General inclusion criteria: patients enrolled in ACMS with therapeutic INR results
and no maintenance warfarin dose changes for the previous three months.
General exclusion/discharge criteria: 80 years or older; home INR monitor use;
recurrent thrombotic event or major bleeding history; recent INR values less than
1.5 or greater than 5.0; episodes of being overdue for an INR; requests for more
frequent testing.
Eligible patients were offered the option of extending their INR testing frequency to
every 6 weeks. The standard process followed by the ACMS includes:
Reminding the patient to contact ACMS if there are changes to medications, diet,
scheduled procedures, and/or clinical status. This occurs at the time of protocol
enrollment and with each subsequent INR assessment.
Informing the patient that more frequent INR tests will be required if subsequent
results are outside of goal range; clinically significant to medications, diet, or clinical
status occur; warfarin is held as part of a peri-procedural plan; or episodes of being
2 weeks or more overdue for an INR test arise.
Standardized documentation in the electronic medical record was defined.
The protocol was reviewed and a plan to pilot over a 6 to 12 month period was enacted:
Healthcare Associates QI Committee and ACMS Leadership approved the protocol.
ACMS staff were trained regarding the new protocol and completed a competency
test before proceeding independently with patient assessment and enrollment.
The protocol was initiated into ACMS daily practice in February 2013.
Measurements of Improvement:
Clinic adherence to the protocol.
Decreased INR test burden and increased convenience for patients.
Maintenance of INR results within range and overall safe warfarin care.
Findings to date:
Patients were enrolled in the extended INR testing protocol and electronic medical records
were reviewed to assess outcomes at 6 and 11 months following piloting of the protocol.
Overall staff adherence to the extended INR testing protocol process was 95%.
Analysis was performed on patients with at least 12 weeks of data over the last 11 months:
58 patients enrolled
41 males (71%), 17 females (29%)
Average age 67 years (range 41-79)
45 anticoagulated for cardiac condition (78%; 37 patients (82%) with atrial fibrillation/flutter), 13 for DVT/PE (22%)
Duration of anticoagulation: <1 year: 2 (3%) ; 1-5 years: 31 (53%) ; 6-10 years: 16 (28%); >10 years: 9 (16%)
46 patients with > 12 weeks data
Average length of time on protocol 40 weeks (range 14-48)
402 INR results were recorded:
Reasons for early
Days
INR tests
between
INR results
[Average
(range)]
INR results
INR results Reasons recorded for Dose adjustments
within goal range outside goal out of range INRs
(% of occurrences)
range by
>0.2
29 (1-88)
315 (78%)
MD appointment
Hospital admission
Pre/post procedure
Antibiotics
Last INR outside goal
38 patients (83%)
had >65% INRs
within goal range
88 (22%)
Unknown (48%)
Illness (18%)
Dietary change (16%)
Periprocedure (8%)
Dosing error (7%)
Interacting med (3%)
66 one time changes
32 weekly changes
Clinical events that were noted during the pilot period included:
2 patients stopped warfarin (failure to thrive and apixaban conversion, respectively).
1 patient moved out of state and transitioned to a local anticoagulation service.
13 hospitalization episodes involving 9 patients: influenza-like illness (#2), mechanical fall
(#2), failure to thrive (#2), TIA/stroke (INR within goal) (#1), epistaxis (INR 3.39) (#1), atrial
fibrillation (#1), atrial tachycardia s/p PVI (#1), leg injury (#1), non-warfarin allergic reaction
(#1), ileus (#1).
o 2 patients were discharged to rehabilitation facilities following hospitalization.
9 patients had procedures performed: colonoscopy (#3); endoscopy (#1); epidural steroid
injection (#1); eye surgery (#1); prostate biopsy and seed placement (#1); PVI (#1); rectal
banding (#1)
4 patients were 2 weeks or more overdue for an INR tests. One patient had four overdue
episodes of 2-4 weeks. Six subsequent INR tests (86%) were within goal range.
No patients met protocol discharge criteria.
Key Lessons Learned:
A standardized multidisciplinary process for addressing new clinical guidelines is an
effective method for evolving patient care in safe manner.
Extending INR interval to 6 weeks in stable patients appears to provide safe care in pilot.
Next steps include continuing to monitor and track patient success in the pilot program;
refining protocol inclusion criteria based on additional data; and standardizing protocol
resumption following temporary discontinuation (e.g. out of range INR, overdue episodes).
Acknowledgements:
BIDMC Coumadin Clinic team members include: Patricia Glennon, RN; Lisa Jachowicz, LPN; Marie
Mahony, RN; Colleen Monbleau, RN
For More Information, Contact Jennifer E. Mackey, PharmD: jemackey@bidmc.harvard.edu
¹ February 2012; 141(2_suppl) Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians
Evidence-Based Clinical Practice Guidelines
�
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Title
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Silverman Symposium
Description
An account of the resource
Each year the Silverman Symposium poster session offers BIDMC staff and affiliates the opportunity to share experiences and learn about efforts to improve Quality and Safety.
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Silverman Poster
Primary Contact
If you would like more information about this project, contact this person. Make email address clickable.
Jennifer Mackey (<a href="mailto:jemackey@bidmc.harvard.edu">jemackey@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Medicine
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Patricia Glennon
Lisa Jachowicz
Marie Mahony
Colleen Monbleau
Dublin Core
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Title
A name given to the resource
ACMS Stable Patient Extended INR Protocol as a Model for Reviewing, Assessing, and Implementing New Clinical Guidelines into Patient Care Practices.
Date
A point or period of time associated with an event in the lifecycle of the resource
2014
Format
The file format, physical medium, or dimensions of the resource
pdf
Compliance
Efficiency
-
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d22182a77509f66446fa2a782857ec03
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ActionOI: Operational Benchmarking
Brenda Ball, Ted Vander Linden
BIDMC
Introduction/Problem
While clinical quality and outcome benchmarking (Vizient/UHC) has helped to guide and inform improvement initiatives for years at BIDMC, historically
there has not been an equivalent, hospital-wide standard for operational benchmarking. Improving facility and department level insights into BIDMC’s
resource utilization relative to peer Academic Medical Center’s was identified as a priority in FY17, intended as a tool and resource for decision makers
at all levels of the organization.
Aim/Goal
The intervention
Advance data-driven decision making and improvement planning around resource
utilization (space, labor, supplies, etc.) through a peer benchmarking platform,
specifically with respect to:
Capacity/Access: Service intensity and utilization across all departments –
inpatient, ambulatory, centralized services, etc.
Cost: Operational expenses related to service delivery; insights into
investment and cost-reduction opportunities as the organization targets longterm financial stability.
Implement ActionOI. an industry-standard operational benchmarking platform
Conduct ongoing VP, director and manager level trainings on data collection
and reporting
Incorporate operational benchmarking into organizational decision making
and improvement planning at all levels of the organization
The Team
Project Sponsor: Senior Leadership
Project Leader(s): Sarah Moravick, Eileen Simons
Team Members: Brenda Ball, Sarah Moravick, Eileen Simons, Ted Vander Linden
For more information, contact:
Brenda Ball, ActionOI Program Coordinator, bcball@bidmc.Harvard.edu
�ActionOI: Operational Benchmarking
Brenda Ball, Ted Vander Linden
BIDMC
Results/Progress to Date
Established quarterly feeds from financial
statements, general ledger, payroll and CCC
Mapped 316 departments across the medical
center that now have access to quarterly
benchmark reports
Established centralized reporting and
distribution standards with all of Patient Care
Services
Next Steps
Assist in the budget and planning cycles
(when requesting New positions)
Identify opportunities for performance
improvement
For more information, contact:
Brenda Ball, ActionOI Program Coordinator, bcball@bidmc.Harvard.edu
�
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Title
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Silverman Symposium
Description
An account of the resource
Each year the Silverman Symposium poster session offers BIDMC staff and affiliates the opportunity to share experiences and learn about efforts to improve Quality and Safety.
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Silverman Poster
Primary Contact
If you would like more information about this project, contact this person. Make email address clickable.
Brenda Ball <<a>bcball@bidmc.harvard.edu</a>>
Department
Any departments listed on the poster or identified in the spreadsheet.
Office of Improvement & Innovation
Project Team
Senior Leadership
Sarah Moravick
Eileen Simons
Brenda Ball
Eileen Simons
Ted Vander Linden
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
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Title
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ActionOI: Operational Benchmarking
Date
A point or period of time associated with an event in the lifecycle of the resource
2018
Format
The file format, physical medium, or dimensions of the resource
pdf
Effectiveness
Efficiency
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/56b7daea518db055ae7a70dd9028e71a.pdf?Expires=1712793600&Signature=QsC2DI2ZDzkXBdEW4NmqGUYzuVYFjG55SczMod7PqljiTmH02AzQiPKanZjHM-s2VfxNpn4Eb861XHiQP32gFCx7p5CL39DWQ9wOO9HB2go4a-QoJohHQAguGTYylK4jK%7EgQodvaFa4Zn74lmI58DuJx7XCD5EpVGBsyUL0-Jg6nK-W%7Euo0w464X4HX-EIduANDDMRFUQ82tdbMHwziIi26ar0rNEoe1gTCwEBZQOLNcI1a6gk-r3VXXgGOGuvVClGy8CA9RFKdNFEFnnLXYIPF8-bXmv5q0rmCThHcUINJKe1hMtXD6h8XNJCzn%7EUiE8uUZmjImUotywZSwexNaiQ__&Key-Pair-Id=K6UGZS9ZTDSZM
708783c825965a6664a7f543389c69cc
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Acuity-Link: Improving Inefficiencies in Patient Transports
By: April Palmquist CMRP, RLLD
TAP TO GO
BACK TO
KIOSK MENU
Introduction/Problem
The Interventions
Patient transportation to and from the Medical Center is a manual and unpredictable process.
Ambulance transports cause bottlenecks in the discharge process impacting patient throughput
and the patient experience. Likewise, ambulatory patient transports traditionally use taxi vouchers
to transport patients home. The voucher system is antiquated, costly, and easily abused.
➢ The Emergency Department was first to pilot the ambulance and ambulatory patient transport
dashboard in April, 2018. The ED provided important feedback throughout the pilot to enhance
the user experience and make scheduling patient transports effortless for the end user.
➢ BIDHC Chelsea, Social Work, and the Service Ambassadors were heavily involved in the
ambulatory patient transport pilot. Departments scheduled rides for patients through AcuityLink’s partnership with Lyft.
➢ Data was gathered on the number of departments and their spend associated with transporting
patients using the existing taxi voucher system. We used this data to pinpoint areas for the
next phase of Acuity-Link’s implementation.
Our current transportation model is inefficient which causes dissatisfaction for both patients and
staff. Supply Chain and members of the Emergency Department, Ambulatory, and Social Work
were determined to find a better, more reliable way to safely transport our patients to their next
destination.
Similarly, Acuity-Link understood the same problem and created a centralized transportation
dashboard to connect hospitals directly with transportation companies to ensure efficient
transportation for patients.
Through our partnership with Acuity-Link, BIDMC has seen improvements in safety, satisfaction,
and reliability of patient transportation with the implementation of Acuity-Link’s centralized
transportation dashboard.
Aim/Goal
To provide safe and reliable travel for patients to and from the Medical Center at the most affordable rate
while increasing transparency to the current system for all involved—patients, staff, and ambulance
providers
The Team
➢
➢
➢
➢
➢
➢
➢
Chip McIntosh, Senior Director Supply Chain
Steve List, Contract Manager
April Palmquist, Contract Specialist
Lisa Yanovich, Administrative Director, Emergency Room
Kelina Orlando, MBA, Executive Director of Ambulatory Operations
Christine Lyons, Administrative Manager-Operations, Social Work Department
Nicholas Kriketos, Manager, Service Ambassador Program
Results/Progress to Date
The Emergency Department, Social Work, and BIDHC Chelsea found the ambulatory patient
transport dashboard easy-to-use and reliable for ambulatory patient transports. Lyft provides
excellent curb-to-curb service, is always on time, and maintains an affordable rate as compared to
the taxi voucher system.
Acuity-Link and the ED worked closely with our contracted ambulance service provider, Cataldo
Ambulance Service, to further implement and enhance the ambulance transportation platform in
Acuity-Link. Tablets were installed in most ambulances contracted to work at BIDMC as a wat to
enhance visibility and provide real-time estimated times of arrival and GPS tracking of
ambulances.
With the success of the platform in piloting departments, the team decided in February, 2019 to
fully implement Acuity-Link for the remaining in-patient units. Information Systems worked with
Acuity-Link to implement single sign-on making it seamless for end users to log in and request
transportation.
We relied heavily on Social Work to update and communicate the Medical Center’s transportation
decision trees to include Acuity-Link as an option for safe and reliable patient transportation.
BIDHC Chelsea has seen improvements in accountability, protection of patient information, and
improved patient experiences with the successful implementation of the new platform.
For more information, contact:
April Palmquist CMRP, RLLD, Contract Specialist apalmqui@bidmc.harvard.edu
�Acuity-Link: Improving Inefficiencies in Patient Transports
By: April Palmquist CMRP, RLLD
More Results/Progress to Date
Requesting rides for patients has never been so easy and transparent. Acuity-Link takes the place
of the often time-consuming telephone conversations to Cataldo and streamlines patient
information into one safe location.
Average Number of Rides in Four Months Post Implementation
1,593
1,600
Acuity-Link has shown to reduce the request time by up to 75%.
1,500
Operational Improvements:
•
•
•
•
•
1,300
1,200
FY 17
FY 19
Lessons Learned
• The number of requested rides has increased by 8%
• The average cost per ride has decreased by 6% in FY 19
• At this pace, BIDMC could save $7,500 annually in patient transportation with Acuity-Link
Average Cost per Ride in Four Months Post Implementation
$25.76
$25.00
$24.19
$24.50
$24.00
$23.50
$23.00
FY 18
➢ Partnerships with hospital teams like Information Systems, Social Work, Service Ambassadors, Case
Management, Nursing Administration and the Emergency Department, were key to successful
implementation of the new platform
➢ Development of single sign-on allowed us to interface the new platform with our existing user
credentials
Next Steps
$25.50
FY 17
FY 18
The average number of rides has increased 8% from FY 18 to FY 19
Financial Improvements:
$25.45
1,386
1,400
Reduced delays and minimized bottlenecks
Improved patient throughput
Enhanced patient care and experience
Alignment of discharge time with arrival of the medical transportation
Ability to pre-plan discharges and transfers hours or days prior
$26.00
1,468
➢ Maintain our partnership with Acuity-Link and Cataldo to monitor transports and improve the user
experience for patients and staff at the Medical Center
➢ Implement technology in every ambulance servicing BIDMC to enhance visibility and provide
accurate estimated times of arrival
➢ Reduce the use of and eliminate taxi vouchers for ambulatory patient transports and calls to Cataldo
dispatch for scheduling of patient transports
➢ Continue educating end users on the use of the platform
FY 19
The average cost per ride in FY 19 has decreased 6% since instituting Acuity-Link in the first four months of FY 19
For more information, contact:
April Palmquist CMRP, RLLD, Contract Specialist apalmqui@bidmc.harvard.edu
�
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Title
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Silverman Symposium
Description
An account of the resource
Each year the Silverman Symposium poster session offers BIDMC staff and affiliates the opportunity to share experiences and learn about efforts to improve Quality and Safety.
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Silverman Poster
Primary Contact
If you would like more information about this project, contact this person. Make email address clickable.
April Palmquist (<a href="mailto:apalmqui@bidmc.harvard.edu" target="_blank" rel="noreferrer noopener">apalmqui@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Supply Chain
Emergency Department
Ambulatory Services
Social Work
Service Ambassadors
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
BID Healthcare - Chelsea
Project Team
Chip McIntosh
Steve List
April Palmquist
Lisa Yanovich
Kelina Orlando
Christine Lyons
Nicholas Kriketos
Dublin Core
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Title
A name given to the resource
Acuity-Link: Improving Inefficiencies in Patient Transports
Date
A point or period of time associated with an event in the lifecycle of the resource
2019
Format
The file format, physical medium, or dimensions of the resource
pdf
Effectiveness
Efficiency
Safety
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/5cddf11d65df7bd8a0122d52ac48e7db.pdf?Expires=1712793600&Signature=RXKNqJa2ztI03ENJSeNaMZUjSTKiJoualVS4KuPLddkR6JdUAZ80C7K7ipdic4VvrKWoowSky5L4B49jIOV8Cul%7EZDFaTqAcCAvJdqgtIDzX3Miw0ur9nXLvIF81FmhzvYTy543d2GeiaEsdhDOWwsoOehvi-FYJ6ouvEZ-AMfpOZgLuGltreRV7XeQiXekkqB1lJ4gYQwege1rm3d938xZJNS5uXv40UIS4wqB0B14noLX3OvOI2Yd0Hts7scmFkoyq1zO1fnkmta1Ztb7wKNCroSUreWJv-FSu3Yy4bdF%7EyQ4Ksqrnq8vMl7JxZIDEMsBPoCTQciLqQdnxfaWiTw__&Key-Pair-Id=K6UGZS9ZTDSZM
5f348c840976e5bc84f853f4a8c94461
PDF Text
Text
Adapting Interpreter Services to a Hybrid Model during COVID
Shari Gold-Gomez, Jordan Ellis, Interpreter Services Supervisor Team, and the entire Interpreter Services department
Introduction/Problem
In January 2020, Interpreter Services moved from a long-time paging system to a just-intime interpreter request software.
Two months later, in March 2020, Interpreter Services used this just-launched system to
enable appointment dispatching to approximately 50 interpreters, representing over 15
languages. We quickly increased to over 30 languages representing 100 interpreters,
including staff, per diem and non staff.
This quick transition to a hybrid model within 48 hours allowed BIDMC to maintain
communication and service delivery to LEP patient population.
Aim/Goal
The goal of this work was to provide seamless service delivery to the LEP patient population
in virtual, ambulatory, and inpatient settings during the COVID-19 pandemic.
The Team
Ø
Ø
Ø
Ø
Ø
Shari Gold-Gomez, Director, Interpreter Services
Jordan Ellis, Project Manager, Improvement & Innovation
Stephanie Baumeister, Operations Manager, Interpreter Services
Supervisors: Ana Torres, Janice P Chung, Ernestina Damoura Moreira, Rina Levin
The entire Interpreter Services department
The Interventions
Ø We first piloted remote interpretation with large
language teams in the weeks leading up to
March 13, 2020. We then had a proof of concept
that it was possible to provide interpreter
Ø
services remotely.
Ø We then changed protocols and began taking
hospital-issued devices home to be prepared for
remote work prior to March 13,2020.
Ø After the March 13th announcement that clinics
were closing, Interpreter Services changed their
configuration to base a minimal number of staff
on site with the balance of interpreters at home
ready to work remotely via the dispatching
software. The outcome was successful to adapt
the dispatching software to allow interpreters to
safely work from home while maintaining an onsite presence for complex patient interactions.
Donated clinical iPads were configured for ease
of use with Starleaf and interpreters on selected
inpatients floors for video interpreting.
Year
2019 (scheduled
interpreters)
2021 (hybrid model,
dispatching software)
Average Response Time
(Minutes)
15 minutes
5 minutes
Results
40,000 more encounters since FY18 with the
This project allowed a hybrid model to both
same staffing.
allow a key on site presence of interpreter,
with the balance of 100 interpreters to work
remotely: providing video and telephone
interpreting which had never been done
before by BIDMC interpreters.
This current models allows Interpreter
Services to serve 18% more encounters for
LEP patients and providers with the
efficiencies gained by not traveling and waiting
in a just-in-time model compared with FY 18
levels. This equates to supporting more than
For more information, contact:
Shari Gold-Gomez
�
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Title
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Silverman Symposium
Description
An account of the resource
Each year the Silverman Symposium poster session offers BIDMC staff and affiliates the opportunity to share experiences and learn about efforts to improve Quality and Safety.
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Silverman Poster
Primary Contact
If you would like more information about this project, contact this person. Make email address clickable.
Shari Gold-Gomez (<a href="mailto:sgomez@bidmc.harvard.edu" target="_blank" rel="noreferrer noopener">sgomez@bidmc.harvard.edu</a>)
Project Team
Shari Gold-Gomez
Jordan Ellis
Stephanie Baumeister
Ernestina Damoura Moreira
Ana Torres
Janice P. Chung
Rina levin
Interpreter Services Department
Department
Any departments listed on the poster or identified in the spreadsheet.
Interpreter Services Department
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
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Title
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Adapting Interpreter Services to a Hybrid Model during COVID
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Format
The file format, physical medium, or dimensions of the resource
pdf
Compliance
Effectiveness
Efficiency
Patient and Family-Centeredness
Timeliness
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/2ebaeedf43d8d81d5f469a9e96f1107b.pdf?Expires=1712793600&Signature=t3aPJHRxADbjhkkSidkCAjtz3hEzfu2HhB33uR%7EiPcxJ5mtVEBe0GZ%7E7ay3YOtFjLuXVW24KFbp2OhFe%7E6P3NdPYTmxG0yKdCNnCV2D26GR88uDzK3Y6yaS1DvR3RznsEmaFEvpHCpQIPEUaDNKTDowEp-GrOoVGjSY3To8wTZBK5D3YJMIEQDVm%7ElxONVf5VtXH3IZoUjsHr363kCaj5m2Vzq6Sgm6u0C%7EQT-tyxqVrY6Vkj%7ES3SUxHU64NO%7EZyQbwu6p4qPazeGHe2oaf3KofR0EHobwwsocu8OagNv60XF8Pb8vGlzSrymh8dPoj2i7JkK6SD4kt6ALHYpzBLuw__&Key-Pair-Id=K6UGZS9ZTDSZM
5967d3a93da7129834614d6252f717e1
PDF Text
Text
Add‐On Team
A Faculty Hour Team
IV. Solution
I. Background
Unscheduled cases that unexpectedly require surgery and must be added on to the OR schedule represent both a high priority and a
dilemma to the OR care team. How should cases of varying levels of urgency and emergency be classified and handled while continuing
to provide optimal care to all surgical patients? How can the needs of urgent, complex surgical patients be met, particularly when
resources are constrained on nights and weekends? How can a communication system be instituted to serve all team members in a
timely and reliable way? This team will benchmark other institutions that have re‐designed perioperative flow and test best ways to
improve access, safety, and efficiency as well as clinician satisfaction regarding add‐on cases at BIDMC.
GOALS:
1. Develop and implement a priority‐based system to define the order of cases. Concerns include:
• When booked?
• Urgency?
2. Make resources evident and ensure that they are communicated early
3. Optimize matching of resources and expectations
4. Improve the communication system between the anesthesia floor manager, front desk, surgeon and resident
Project Team
Mary Austin
Seema Chowdhury, MD
Jane Cody
Jonathan Critchlow, MD
Alok Gupta, MD (Co‐Leader)
Stephanie Jones, MD
Pete Panzica, MD
Beth Person (Co‐Leader)
Verna Rettagliati
Edward Rodriguez, MD
Dottie Sarno
Ross Simon (Facilitator)
Jason Wakakuwa, MD (Co‐leader)
Sponsor: Richard Whyte, MD
II. Current Condition
III. Analysis
For More Information Contact
Alok Gupta, MD agupta4@bidmc.harvard.edu
Beth Person, bperson@bidmc.harvard.edu
Jason Wakakuwa, MD jwakakuw@bidmc.harvard.edu
�
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Title
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Silverman Symposium
Description
An account of the resource
Each year the Silverman Symposium poster session offers BIDMC staff and affiliates the opportunity to share experiences and learn about efforts to improve Quality and Safety.
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Silverman Poster
Primary Contact
If you would like more information about this project, contact this person. Make email address clickable.
Jason Wakakuwa (<a href="mailto:jwakakuw@bidmc.harvard.edu">jwakakuw@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Nursing
Anesthesia
Surgery
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Mary Austin
Alok Gupta
Verna Rettagliati
Jason Wakakuwa
Seema Chowdhury
Stephanie Jones
Edward Rodriguez
Jane Cody Pete Panzica
Dottie Sarno
Jonathan Critchlow
Beth Person
Ross Simon
Richard Whyte
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Title
A name given to the resource
Add-On Team
Date
A point or period of time associated with an event in the lifecycle of the resource
2014
Format
The file format, physical medium, or dimensions of the resource
pdf
Effectiveness
Efficiency
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/fa44939ad883df39e08b672b7f88244d.pdf?Expires=1712793600&Signature=PXNP-hjBu3ZQ9oLNLNCh6WY3iI9cxqyYhFORl0sm7cV5Qmsutm3sSpMAz3MsCJS6S%7Ea7IrAtS56BZINxhwTsdsHDiHL0Piv2PnSkW1XDG9qq4xgufz7bTP9BDC14MUxR2WIzASaGe6cLW5y9FIM5vWE9TzKK-GJLMRii6%7E9GupCbI4X6OAIbHYjyxMrBtmcXJsHa7%7EC-hO7q2O2ZHpczxmq%7ELZyrXZMviNPvfLZNo5ZNxBa7lv8GL56rUqW9eHwtQWLkoZ6W0Uj275JO5UPlEtS7oBGwWsUsLplMbHGBeRH5LcqmH6nUcD6dGJbQ6T94KKanyQUE1YMGlZgO2qFu-A__&Key-Pair-Id=K6UGZS9ZTDSZM
2bd089c9ad8473d914a11c3237b88960
PDF Text
Text
Adding Value- The New Glover Cafe
The Problem
The Glover Café at BIDN has been a tradition in the Needham communityserving the hospital’s many employees, patients, and even local residents. Until 2013,
the Café stood in its small corner of the old hospital wing with a handful of tables and
limited food production capabilities. Though the old Café was a favorite of many, wait
times were long, food production was limited, and there was little room for growth. As
a result, the potential for increased sales and transactions was minimal. With the
hospital continuing to expand, there was a need for a larger facility in order to provide
the best service possible to our many loyal customers.
In July 2013, the new Glover Café opened. More than triple the size of the
previous space, it now offers a variety of cold and hot food and beverage options. The
Café includes a hot entrée line, a salad bar, a deli station, a soup station, smoothies,
coffee, cold foods and beverages, and more.
The Results/Progress to Date
53.8% increase
frpm FY2012
Aim/Goal
Our goal was to increase the value in the new Glover Café, as measured through
both qualitative measures (customer comments, feedback forms) and quantitative
measures (revenue, average sales, transaction average, rate of capture).
Katie Laycock- Sodexo, General Manager
Michele Morgan RD LDN Sodexo Clinical Nutrition Manager
Erin Boudreau- Sodexo, Executive Chef
Monica Vasquez, Francesca Serpa, Don Regan- BIDN Staff
Lois Marks, Helaine Yanofsky- BIDN Volunteers
The Interventions
“The space is
really inviting
and uplifting”
‐ customer
In January 2013, the old Glover Café closed.
An interim Café was established from January-June 2013
The new Glover Café opened its doors in July 2013.
Quantitative measures of value were gathered, including revenue, average
weekly sales, average rate of capture, and transaction average
Qualitative measures of value were gathered, including customer comments
and feedback forms
Customer-oriented initiatives in the Glover Café:
o
o
o
o
o
Lessons Learned
The Team
Meatless Mondays and Wellness Wednesdays
BIDMC Chef Series
New Product Tastings
Pedometer Challenge and Employee Wellness
Seasonal Farmer’s Market
The new Glover Café has resulted in increased annual revenue, average
weekly sales, and rate of capture. The trends for these quantitative
measures of value have not plateaued and continue to increase.
o Annual revenue in 2012 was $143,412.00 and annual revenue in
2013 was $203,018.00.
o Average Weekly Sales skyrocketed from $13,000/week in 2012 to
$20,000/week in 2013- these continue to increase in 2014.
o Average Rate of Capture for 2012 was 21% and for 2013 it
increased by 14% to 35%.
Though many are nostalgic for the old café, customer comments about the
new Glover Café have been overwhelmingly positive. We continue to see
more and more customers in the new space.
Customer-oriented initiatives, such as the Farmer’s Market and Product
Tastings, have helped bring awareness to the new Glover Café and its many
offerings. These initiatives have also helped to add value to the space.
Next Steps
Continue to track quantitative and qualitative measures of value
Continue to promote the new Glover Café and increase rate of capture
Continue with customer-oriented initiatives and other community activities
For more information, contact:
Jeanine LeDoux, MS RD LDN
Sodexo Food and Nutrition at BIDN
jledoux@bidneedham.org
�
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Title
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Silverman Symposium
Description
An account of the resource
Each year the Silverman Symposium poster session offers BIDMC staff and affiliates the opportunity to share experiences and learn about efforts to improve Quality and Safety.
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Silverman Poster
Primary Contact
If you would like more information about this project, contact this person. Make email address clickable.
Jeanine LeDoux (<a href="mailto:jledoux@bidneedham.org">jledoux@bidneedham.org</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Food Services
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BID-Needham
Project Team
Katie Laycock
Michele Morgan
Erin Boudreau
Monica Vasquez
Francesca Serpa
Don Regan
Lois Marks
Helaine Yanofsky
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Title
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Adding Value - the New Glover Cafe
Date
A point or period of time associated with an event in the lifecycle of the resource
2014
Format
The file format, physical medium, or dimensions of the resource
pdf
Efficiency
Patient and Family-Centeredness
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/5883bcb04f1dcd626ff8b9172e55989f.pdf?Expires=1712793600&Signature=jS0BLvDiOrwUewEtSvSi-JSzqmpowE-DIApB6VXGhpESXjv8ATV9vrn4TdkM%7EHUr4IzCY-C3SZfKfFRhiY66ZQ6SdqscejEhhWJMncylzf9%7EJAJ9kq8jheaTH4WDwBomRHHOfm2s3jFMDupSscjvsw9D0MgPn4P5FlzFGVpoO5AxdeGS0LR3VZCUcD6efSGyLSM4qOFkFTzyR7WohPeoiwPDd2xmx98RIDQP6kWuFjddPEHkCG101RYfwjIY7LZmC9jX-pixQdaFOUc7TQelYUNFMsNHyJDA%7EM2G4Y3JcCM3ryKPrX64QfGkCXpIXzV7I7rS3j3WevdnxktiMiZn6Q__&Key-Pair-Id=K6UGZS9ZTDSZM
2a5d2341b474e6d90f263bcb78f8c782
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Text
Addressing the Gap in NAFLD Screening
Nathan Sairam, MD1; Eddy Leung, MD1; Hirsh Trivedi, MD2, Jonathan Li, MD3; Michelle Lai, MD2
Department of Medicine1, Liver Center2, Health Care Associates3
Beth Israel Deaconess Medical Center
Introduction / Problem
Methods
● Non alcoholic fatty liver disease (NAFLD) is a spectrum of liver disease that causes steatosis of the
liver in the absence of alcohol consumption.
● 50% of cases of advanced fibrosis from NAFLD are not discovered until they present with
decompensated cirrhosis, which has an 85% 5 year mortality without transplant.
● The incidence of NAFLD is projected to increase significantly by 2030 and will cause increased
incidence of NASH cirrhosis, HCC, and associated complications.
● NAFLD currently leads to $103 billion dollar in medical expenses annually.
● Diabetics have very high rates of NAFLD, with some studies showing 71% of diabetics having NAFLD.
● 23.1% of diabetic patients have F3-F4 fibrosis, which would warrant HCC and variceal screening.
● The American Diabetes Association currently recommends screening patients with diabetes for NAFLD
with yearly LFTs.
● 50% of diabetics with NAFLD and 56% of diabetics with NASH actually have normal LFTs.
● Fibroscan screening has the potential to identify patients with F3/F4 fibrosis with higher sensitivity
allowing for more early identification of HCC and varices.
● Using Arcadia, we generated a list of 101 diabetic patients seen at HCA clinic by three of our study
members.
● All patients were manually chart reviewed to determine whether or not they were getting yearly LFT
screening. Any patients with a 2 year or greater gap with no LFTs starting from the time of their
diabetes diagnosis was considered to not be getting yearly LFTs.
● All patients were chart reviewed to determine if they ever had persistently abnormal LFTs on at least 2
consecutive checks at any point in time.
● We reviewed prior imaging to determine if patients ever had incidental findings of steatosis of the liver.
Results
37% of patients with
diabetes were not being
screened yearly with LFTs
Aim / Goal
● Identify patients with F3/F4 fibrosis prior to presentation with decompensated cirrhosis and enroll
these patients into HCC and variceal screening pathways.
● Retrospectively review a cohort of patients with diabetes in the primary care setting to determine how
well we are currently adhering to the ADA’s current guideline of yearly LFT screening.
● Determine how often fibroscans are ordered for patients with abnormal LFTs or steatosis on imaging.
● Determine feasibility of direct to fibroscam screening strategy.
59% of patients with
diabetes had past or present
abnormal LFTs or imaging
showing steatosis but had
never received fibroscan
Conclusions / Next Steps
At HCA clinic, there is poor adherence to the current ADA guideline recommendation for yearly LFTs to
screen for NAFLD among diabetic patients. Furthermore, the majority of diabetic patients have had
abnormal LFTs or incidental steatosis of the liver on imaging at some point in their care but have not been
ordered for fibroscan to follow this up. Offering one-time fibroscan may therefore be a superior screening
strategy. We developed a call outreach effort to offer fibroscan to these patients. The outreach effort and
our results are described on the following slide.
For more information, contact:
Nathan Sairam (nsairam@bidmc.harvard.edu)
�Patient Perceptions about NAFLD and its Screening
Eddy Leung, MD1; Nathan Sairam, MD1; Hirsh Trivedi, MD2, Jonathan Li, MD3; Michelle Lai, MD2
Department of Medicine1, Liver Center2, Health Care Associates3
Beth Israel Deaconess Medical Center
Aim/Goal
Results continued
• Ascertain patient-related barriers to NAFLD screening by gauaging knowledge and interest in NAFLD
screening in patients by outreach calls
• Implement a direct-to-fibroscan approach to NAFLD screening for those patients who agree to be
screened with this approach
Methods
79%
A subset of patients were identified
through Arcadia and sorted with
exclusion criteria. The remaining
patients were contacted with outreach
calls using a standardized script
Number of Responses
Results
Number of Responses
What Patients had to say:
● “My liver numbers (liver function tests) are excellent. What else would
justify doing it (fibroscan)?”
● “Do my [diabetes specialists] know about this? None of them mentioned
anything about fatty liver disease.”
● “I have an appointment with my primary care doctor tomorrow. I want to
talk to [them] about it instead.”
● Patient was afraid the call meant she had fatty liver disease because nobody
had mentioned it to her before.
● Patient stated she was nervous about the [fibroscan] results because she
knows diabetes is bad and it “puts you at risk for everything.”
Conclusions
• Knowledge and awareness about NAFLD are low among patients with T2DM. For many, it had not
been discussed by their primary care doctors or specialists.
• Most patients intuitively believe that fatty liver disease is serious and warrants screening.
• Patient hesitancy regarding NAFLD screening may be improved by discussions initiated by the primary
care doctor as part of healthcare maintenance.
• Outreach calls using a standardized script may be an effective method in improving rates of NAFLD
screening in patients with T2DM.
Next Steps
1-10 scale where 1 is not serious at all and 10 is among the most serious
medical conditions
• Follow up on fibroscan completions rates in three months from the time they were ordered to
determine adherence
• Follow the results of fibroscans ordered. This may inform whether a direct-to-fibroscan approach
identifies advanced fibrosis in those who otherwise would not have been screened according to
guidelines that recommend liver function testing.
For more information, contact:
Eddy Leung (eleung3@bidmc.harvard.edu)
�
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Silverman Symposium
Description
An account of the resource
Each year the Silverman Symposium poster session offers BIDMC staff and affiliates the opportunity to share experiences and learn about efforts to improve Quality and Safety.
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Silverman Poster
Primary Contact
If you would like more information about this project, contact this person. Make email address clickable.
Nathan Sairam (<a href="mailto:nsairam@bidmc.harvard.edu" target="_blank" rel="noreferrer noopener">nsairam@bidmc.harvard.edu</a>)<br />Eddy Leung (<a href="mailto:eleung3@bidmc.harvard.edu" target="_blank" rel="noreferrer noopener">eleung3@bidmc.harvard.edu</a>)
Project Team
Nathan Sairam
Eddy Leung
Hirsh Trivedi
Jonathan Li
Michelle Lai
Department
Any departments listed on the poster or identified in the spreadsheet.
Department of Medicine
Liver Center
Health Care Associates
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Addressing the Gap in NAFLD Screening
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Format
The file format, physical medium, or dimensions of the resource
pdf
Compliance
Effectiveness
Efficiency
Patient and Family-Centeredness
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/b112bdd6b5b7d5ee9b567b155adfba06.pdf?Expires=1712793600&Signature=G0Y1sVTsffZerTUb6ZPlXA%7Er5JRxctUmaXgqlHr2eMMhEFRYlLfN3N3e6TuJ9zil3ccRtYnSnqT9yycR%7ElCfQGkxpwLE%7EZPvIySQM527HeUM5%7EJ3MBwxDH2bhVSCScAjZbCGzrwosxAaLB5AArlMFjkOQCyhQg9zYp-UXjUES1h-INOS0gu9y9U6NOq4pBbxY-ocIb-Sw243-IS7BTao656C%7EjEFqf4pzGwXAP6ZTwjtK19HSLaQLaERykCoy4tdUlYVmicrWyfA0t5ST8hP9GST4GGq9luVrJf1rabPV4%7EfNQKrCD%7Ee%7Es2Jci%7Ejaf6cmRZgOEXJoueWfgtVgPjBoQ__&Key-Pair-Id=K6UGZS9ZTDSZM
d34267c82dbcad52c7d893b9ec8075fa
PDF Text
Text
Advancing Quality Assessment in Pancreatic Surgery
Defining the Role of the IOM Healthcare Quality Domains
The Problem
The Institute of Medicine (IOM) defines healthcare quality across six domains:
safety, timeliness, effectiveness, patient centeredness, efficiency, and
equitability. Traditional quality metrics in high-acuity surgery (volume and mortality)
cannot alone measure or satisfy these domains. We asked experts in pancreatic
surgery (PS) whether broader quality metrics are needed, how important they might
be, and whether they align to contemporary IOM healthcare quality domains.
Aim/Goal
The aim of this survey was to identify the most actionable and meaningful measures
to include on a scorecard measuring quality in pancreatic surgery. An effective
scorecard item is defined as being highly important to respondents and aligning with
more than one IOM quality domain.
The Results/Progress to Date
90% of Rpds indicated a definite or probable need for improved quality metrics in PS.
81% of Rpds indicated a definite or probable value for a “Quality Scorecard” in PS. Of 13
PS quality metrics rated as Essential by >25% Rpds, 10 aligned most strongly to the IOM
Safety domain. 22/62 proposed metrics aligned to more than 1.75 IOM Domains, and
were rated by >50% Rpds as High LoI (Essential or Very Important; Figure). 12 proposed
scorecard metrics (Table) emerged with the highest TQS. Those related to mortality, to
the rate and severity of complications, and to access to multidisciplinary services for
pancreatic disease had the highest TQS. Technical and peri-operative metrics had
intermediate TQS. Metrics related to patient satisfaction with care, costs of care, and
patient demographics had the lowest TQS. The least represented IOM domains were
equitability, efficiency, and patient-centeredness.
Lessons Learned
The Team
•
•
•
•
•
Brian T. Kalish - Harvard Medical School (HMS IV)
Charles M. Vollmer, MD - Chief, Pancreatic Surgery, University of
Pennsylvania
Jennifer F. Tseng, MD - Chief, Division of Surgical Oncology, BIDMC
Tara S. Kent, MD - Division of General Surgery, BIDMC
Mark P. Callery, MD - Chief, Division of General Surgery, BIDMC
The Interventions
Together with a professional market research firm, we created and distributed a webbased survey to pancreatic surgeons. These experts were identified through PS
specialty societies, and verified by survey demographics. Respondents (Rpds) ranked
62 proposed PS quality metrics on level of importance (LoI). Next, Rpds aligned each
metric to one or more IOM quality domains (MDA, multi-domain alignment).
Descriptive statistics were used to summarize responses. To calculate and rank
relative quality scores, points were awarded for LoI (4-Essential, 3-Very important, 2Somewhat important, 1-A Little important, 0-Not important) and MDA (1 point/each
aligned domain). LoI Scores and MDA Scores for a given quality metric were
averaged together to render a Total Quality Score (TQS=LoI + MDA/2) normalized to
a 100-point scale.
We propose a 12-item "Quality Scorecard" for Pancreatic Surgery based on rankscoring of quality metrics that PS experts view as both highly important and aligned with
more than one IOM healthcare quality domain. While the actual performance thresholds
for these metrics require further definition and validation, they may reveal quality to an
extent that volume and mortality alone cannot.
Next Steps/What Should Happen Next
Patient Focus Groups and a formal survey of patients and/or family members
to determine which metrics of quality matter most to them.
Multi-institution prospective validation of a Pancreatic Surgery Quality
Scorecard
For More Information Contact
Mark P. Callery, MD
mcallery@bidmc.harvard.edu
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Silverman Symposium
Description
An account of the resource
Each year the Silverman Symposium poster session offers BIDMC staff and affiliates the opportunity to share experiences and learn about efforts to improve Quality and Safety.
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Silverman Poster
Primary Contact
If you would like more information about this project, contact this person. Make email address clickable.
Mark Callery (<a href="mailto:mcallery@bidmc.harvard.edu">mcallery@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Surgery
General Surgery
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Brian T. Kalish
Charles M. Vollmer
Jennifer F. Tseng
Tara S. Kent
Mark P. Callery
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Advancing Quality Assessment in Pancreatic Surgery: Defining the Role of the IOM Healthcare Quality Domains
Date
A point or period of time associated with an event in the lifecycle of the resource
2012
Format
The file format, physical medium, or dimensions of the resource
pdf
Effectiveness
Efficiency
Equality
Patient and Family-Centeredness
Safety
Timeliness
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/e403b445d8f9689a876bb75d524e391d.pdf?Expires=1712793600&Signature=DSiRhkXdmi2BJqex2ACTd82oqjGmW4pF3eH5z7vnD8XRmcVgsFuGLACf2GX5SQddC8d85m9LHMCfpbPGjaZVilR1FHL9-RVoshHBJ3dRlVQml%7EjZsGu4TSSbbklSka-zg85b0eCUnSCxl0YuwZP12CvQgBP%7Es9SLHFTXz0ygkHZ-8yY0Rxi5vDxktO8sj1OMFzfLbSDIQC4HU4QSdgjFFeKqTW9jp-Rs6sxFD7OLhUpgW5h5G4e7Xkfe-icFmDLpS7g2JLarQdVDrmudAj-kw%7EvJKI-WCLnRWOsJGaMz59VGqWk1QeCIKWBeYhWIlsKNOBHJxRtRFNugn-d9FJEARQ__&Key-Pair-Id=K6UGZS9ZTDSZM
ffd7c8a8b1cb6c32358140b53cfef35c
PDF Text
Text
Advantages of Programming and Implementing an
Internally Developed NICU/Newborn Nursery cPOE
AIM
Beth Israel Deaconess Medical Center
Boston, Massachusetts
RESULTS: cPOE DEVELOPMENT
To develop a Computerized Provider Order Entry
(cPOE) program that mimics the order sets and
forms that were currently being used in the NICU
and Newborn Nurseries.
Original Paper PN Order Form
NICU Daily Orders Entry Screen
cPOE PN Order Form
SETTING
48 bed Level III NICU, Academic Medical Center
Approximately 5,000 deliveries per year
METHODS
IMPLEMENTATION
The team began meeting in June, 2008.
The neonatal formulary weight based dosages
were programmed into cPOE using the existing
renal dosing for adults.
Clinicians worked directly with our medical center
programmers to develop a user friendly cPOE
with good work flow.
The internally developed cPOE programming allowed customization
to include:
a scrolling view of all active orders
the ability for clinicians to make changes and enter new orders
while scrolling through active orders
a total fluid goal bar created by all parenteral and enteral orders
display of birth weight and weight from last 3 days
The cPOE went live in our NICU and Newborn
nurseries on November 29, 2011.
ASSESSMENT
To assess one measure of impact of the cPOE
implementation, we reviewed orders for
parenteral nutrition entry for 3-month periods
prior to and after cPOE launch. Parenteral
nutrition is the most complicated platform within
cPOE. Orders were reviewed for number
requiring revision after pharmacy review.
RESULTS: cPOE ASSESSMENT
Order Revisions Pre- and Post- cPOE
To assess staff satisfaction, a survey was sent to
NICU clinicians in September 2013.
TEAM
Chair: Susan Young CNS
LESSONS LEARNED
Survey of NICU Staff cPOE Users
• Following implementation of cPOE, more pharmacy interventions
were seen with PN orders than with paper order entry.
Babies on PN vs. PN orders with interventions
80.00%
• Developing a PN order for cPOE that could do calculations and
osmolarity checking proved to be a challenge. The paper form was
more time consuming, but communicated changes more clearly
than the cPOE PN order.
70.00%
60.00%
50.00%
Clinical Systems: Laura Ritter-Cox, Mary Biagiotti
40.00%
Dietitian: Claire Shoaie
% Babies on PN
30.00%
% PN orders with
interventions
10.00%
ry
br
ua
Fe
ar
y
nu
ec
e
D
Zinc
2
2
Selenium
Error Subtype
4
Fluids
2
5
• Keep paper orders updated with cPOE format in case there is a
computer downtime.
Potassium
2
L-cysteine
11
Total fluid goal
23
1
PTE
2
2
• Continue to update cPOE to maintain patient safety and reflect
clinical practice changes.
Protein adjustment
PN rate
8
0
• Add a feature to the cPOE PN order entry so that additives that are
held are highlighted rather than deleted.
Fat Emulsion
5
Enteral intake
10
15
n
CORRESPONDING AUTHOR:
Greg Dumas, RPh
gdumas@bidmc.harvard.edu
NEXT STEPS
1
Programmers: Kevin Afonso, Jeanne Hurley, Nan
Zullo
Respiratory Therapist: Nina Koyama
• It is important to retest all aspects of cPOE when it is launched to
insure that the functionality in Test is transferred to Live.
Overall Error Subtypes
Pathology: Gina McCormack
Pharmacy Interns: Jessica Baron, Lauren Escobar
Ja
m
m
ov
e
N
RNs: Radka Arnold, Janine Caruso, Jane
Smallcomb, Deirdre Wooley
Pharmacy Information Systems: Steve Maynard
be
r
er
ob
r
m
be
Se
pt
e
be
r
0.00%
NPs/PA: Aimee Madden, Mary Ann Ouellette,
Mary Quinn, Laura Tannenbaum
Pharmacists: May Adra, Holly Creveling, Greg
Dumas, Christine Huynh, Rena Lithotomos
• Additives held for clinical issues were crossed out on the paper
form making the change visible. With cPOE, the additive is deleted
from the printed form which resulted in ordering and
compounding errors.
20.00%
O
ct
MDs: Munish Gupta, Stephanie Hale, Camilia
Martin, DeWayne Pursley, Vincent Smith
• Internally developed cPOE programs allow clinicians to work
closely with programmers to reflect established clinical processes.
20
25
Dextrose
Calcium, Phoshate
Number of responding clinicians
110 clinicians responded to the survey and 81% felt satisfied with cPOE.
• Continue to evaluate cPOE to insure that it accommodates order
entry for infrequent clinical occurrences.
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Silverman Symposium
Description
An account of the resource
Each year the Silverman Symposium poster session offers BIDMC staff and affiliates the opportunity to share experiences and learn about efforts to improve Quality and Safety.
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Silverman Poster
Primary Contact
If you would like more information about this project, contact this person. Make email address clickable.
Greg Dumas (<a href="mailto:gdumas@bidmc.harvard.edu">gdumas@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Clinical Systems
Nutrition Services
Neonatology
Newborn Nursery
Nursing
Pathology
Pharmacy
Information Systems
Respiratory Therapy
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Susan Young
Laura Ritter-Cox
Mary Biagiotti
Claire Shoaie
Munish Gupta
Stephanie Hale
CamiliaMartin
DeWayne Pursley
Vincent Smith
Aimee Madden
Mary Ann Ouellette
Mary Quinn
Laura Tannenbaum
Radka Arnold
Janine Caruso
Jane Smallcomb
Deirdre Wooley
Gina McCormack
May Adra
Holly Creveling
Greg Dumas
Christine Huynh
Rena Lithotomos
Steve Maynard
Jessica Baron
Lauren Escobar
Kevin Afonso
Jeanne Hurley
Nan Zullo
Nina Koyama
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Advantages of Programming and Implementing an Internally Developed NICU / Newborn Nursery cPOE
Date
A point or period of time associated with an event in the lifecycle of the resource
2014
Format
The file format, physical medium, or dimensions of the resource
pdf
Effectiveness
Efficiency
Safety
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/73ce6b366dccc967a2656cca1bc7811c.pdf?Expires=1712793600&Signature=n1426sDKMfEOuGLzsUI4e%7Em8hnFB16SEOi-fMrtPGLY1g61ejK9J5OR9Mwf8O84LaFIe1lHf7qv610YPNvJp0rfTWYUsUixSgmCjEG8TM%7EP7De0Q03Q4PprKXkU8-hctzTFDyZ7OBz-nO0OBRnmV4q%7E1GJAj-SJ-JSy4BdLx5obqx6-lahdiml9hZvi8CC52OH%7EcHYK%7EQ-jW3e5HlFzcgdZRYRsqeLjJYACmm8at3JxIE1Pi1hOqhX2GQFxZEpaiZgGC6R6NxdJBRUr5KEU1G7Rgp9yqCqDP0rutFa8sveGzWIzIdwrNLt5DxpCuwieqALIKUmxAUr6x-ADq-7t8yg__&Key-Pair-Id=K6UGZS9ZTDSZM
c109ca31011aa1291dfaf010f1266bef
PDF Text
Text
Test Tray Pilot
TAP TO GO BACK
TO KIOSK MENU
Elizabeth Haley, RD, Sarah Littmann, RD, LDN, Kelly Stoner
BIDMC Food Services Department
Introduction/Problem
Implementation
• BIDMC Food Service Department serves ~1660 meals per day between both campuses. Facing high
census numbers and limited FTE’s, it can be challenging to deliver patient meals within our goal of 45
minutes. However, no patient wants to eat cold chicken noodle soup or have items missing from their
tray. For this reason, the patient food service team conducts test trays on a weekly basis.
• To increase satisfaction of patient meals, Patient Service Managers complete 3 test trays weekly to
assess overall quality, temperature, taste, and accuracy.
• The team was already using Advocor to document patient meal rounding. The decision to document
test trays using Advocor aligned with our goals of our department to decrease waste and increase
patient satisfaction.
• With this change, Food Services strives to increase food quality for our patients as well as increase
Press Ganey scores through better utilization of data collected from conducting test trays.
Goals
➢ Increase Press Ganey scores by improving quality of meals
➢ Complete 3 test trays per week and document using Root Cause in Advocor
➢ Utilize data for continuous quality improvement of patient food services
Prior to utilizing Advocor, test trays were documented by manually filling an excel spreadsheet, assessing
the performance of the tray based on the Scoring Guide. The test tray form was then saved on the
computer as well as printed and filed in a binder
The Patient Food Services Team
➢ Elizabeth Haley, RD, Patient Services Ops
West
➢ Brandon King, Patient Services West
➢ Sarah Littmann, RD, Patient Services West
➢ Kelly Stoner, Patient Services West
➢
➢
➢
➢
Kelsey Whalen, RD Patient Services Ops East
Emily Bridges, RD, Patient Services East
Maude Meade, Patient Services East
Stephanie Rioles, Patient Services East
For more information, contact:
Sarah Littmann, RD, LDN, Patient Services Manager slittman@bidmc.harvard.edu
�Test Tray Pilot
TAP TO GO BACK
TO KIOSK MENU
Elizabeth Haley, RD, Sarah Littmann, RD, LDN, Kelly Stoner
BIDMC Food Services Department
Progress to Date
Lessons Learned
We are still in early stages of collecting data that defines the value of assessing test tray data in Advocor.
Mostly significantly, we have improved upon tracking trends related to food quality and temperature, as
well as tray accuracy and cleanliness. Advocor is user friendly, allowing you to source a particular item
that is trending below our quality standards. This has promoted the Patient Services Team to conduct
focused in-service trainings with staff, resulting in improved Press Ganey scores from discharge data for
temperature and quality across both campuses. We will continue to utilize Advocor to identify and
resolve Root Cause problems, educate our staff, as well as enhance the patient food service experience.
The data chart below represents test tray quality improvement over the last three months.
➢ Entering test tray information does not have to be a standard process anymore. We are learning to use
it interchangeably instead of ordering one of every category of food. This leads to quick ways assess
food quality data.
➢ Generates discussion and staff education on proper food preparation methods and procedures that
impact patient safety and quality of food.
➢ The Root Cause analysis tool identifies individual food items that need temperature and quality
improvement.
➢ Helps to track tray accuracy and reduce the number of missing items from trays.
Next Steps
Improved our Chicken
Parmesan recipe after
learning the quality was
continually reported as poor
yet one of our most popular
dishes!
➢ Temperatures are manually entered into Advocor. In the future, we would like a drop down box so that
we can easily evaluate the data from temperatures collected.
➢ Continue to utilize Advocor for menu and recipe development
➢ Managers are currently the only ones trained to utilize Advocor. We would like to educate staff to use
this tool (such as call center employees). This will result in more data and improved quality and
temperature of food.
➢ We have asked Advocor’s development team to integrate a system that reminds managers to test
specific items or diets that have not been tested in a certain amount of time. This will help us
strategically order test tray items.
➢ Working with Advocor to elaborate and improve the Test Tray format and the information being
collected. For example, having a place to upload a picture of the test tray to assess quality,
preparation, and presentation.
➢ Moving all evaluating tools (RSA/CSR Audits, Floor Stock Audits, etc.) to Advocor for easy and quick
ways to evaluate staff
For more information, contact:
Sarah Littmann, RD, LDN, Patient Services Manager slittman@bidmc.harvard.edu
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Silverman Symposium
Description
An account of the resource
Each year the Silverman Symposium poster session offers BIDMC staff and affiliates the opportunity to share experiences and learn about efforts to improve Quality and Safety.
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Silverman Poster
Primary Contact
If you would like more information about this project, contact this person. Make email address clickable.
Sarah Littman (<a href="mailto:slittman@bidmc.harvard.edu" target="_blank" rel="noreferrer noopener">slittman@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Patient Food Services Team
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Elizabeth Haley
Brandon King
Sarah Littmann
Kelly Stoner
Kelsey Whalen
Emily Bridges
Maude Meade
Stephanie Rioles
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Advocor Test Tray Pilot
Date
A point or period of time associated with an event in the lifecycle of the resource
2019
Format
The file format, physical medium, or dimensions of the resource
pdf
Effectiveness
Efficiency
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/39f52a81bfc9755b36c7c359bd14dd82.pdf?Expires=1712793600&Signature=aY8pzlt2TJ%7EU5-0pfc0zMLlilUJPplGEw7vr-SMDRU-TFj6P69NYlllfhnI7ROevmzPa3xuFilOXcPKSq96hRPzSvq23MUAHzyIjcw6BO3t0yUWJUJ3iZfjcHwmXYUQE1RGOhSCVXHs4MB3vNj1bAQfYyz6yQdb3IzFLPNI8CFJxiywQnynXHB7nIs5KVSZzvP83mKtqInDEiQmJ-WD9xs6UHT4WR4ez533ZJIRaxpn3boySn5w0nhKdomes-FJpEQaYKQ%7E3Rs6SeLNcwEBB61UU4-uoa9eYjWpMFANwOaCZjRYpiULObNgPB8tn0Sy6EHn5PC3GRPupY4ylEth2mA__&Key-Pair-Id=K6UGZS9ZTDSZM
365699ef1e2cd7735353bff72e8f287f
PDF Text
Text
Flatware Roll-out
Elizabeth Haley, RD, Brandon King, Sarah Littmann, RD
BIDMC Food Services
Problem
• BIDMC Food Service Department serves ~1660 meals per day between both campuses. Up against
high census numbers and limited FTE’s, it can be challenging to deliver patient meals within our goal of
45 minutes. However, no one wants to start their day off with a cold omelet or eat cold chicken noodle
soup! On the other side, Food Services do not want the temperature of the food to negatively impact
the food quality for the patient. Due to the amount of trays being delivered and time spent delivering
trays throughout the hospital, solutions were sought out to keep the food hotter for longer.
• To combat the problem of hot holding temperatures, the Food Services Department rolled out a new
fleet of high technology flatware in January 2018. The decision to transition to Aladdin Temp-Rite
Flatware was made based on its success and positive feedback from BIDMC satellite locations,
Needham and Milton. With this change, Food Services strives to increase food quality for our patients
as well as increase Press Ganey scores.
Goals
Implementation
New Aladdin Items:
Essence® Entrée Domes
Heat on Demand
Advantage® Entrée Bases
Allure® Insulated Soup
Bowls and Lids
Allure® 8oz. Mugs
Increase Press Ganey scores for temperature by improving patient satisfaction of meals
Improve quality of food by increasing temperature to maximize approval of meals offered
Enhance tray appearance to increase acceptability of trays by patients
The Food Services Patient Services Team
Elizabeth Haley, RD, Patient Services West
Brandon King, Patient Services West
Sarah Littmann, RD, Patient Services West
Mieka Martin, Patient Services Ops West
Emily Bridges, RD, Patient Services East
Maude Meade, Patient Services East
Kelsey Whalen, RD Patient Services Ops East
Gary Visnick, Executive Chef West
Andre Silva, Sous Chef West
Steve Pierce, Exec Chef East
Chris Lumpkins, Sous Chef East
Shana Sporman, MS RD LDN, Director
Chris Weiss MBA, Assistant Director
Michael Hanley, Productions Ops Manager
Chris Minette, MBA Senior Director Food &EVS
Nora Blake, Sodexo District Manager
Previous: Dinex
Current: Aladdin
What’s different?
Soup bowl covers
Bases are heated
before plating
Elegant appearance
For more information, contact:
FoodServiceManagementWest@caregroup.harvard.edu
�Flatware Roll-out
Elizabeth Haley, RD, Brandon King, Sarah Littmann, RD
BIDMC Food Services
Results
We are still in the infancy phase of collecting significant data of the new flatware technology impacting the quality
of food for the patients. However we saw an immediate difference in hot holding temperatures by conducting test
trays emulating the food delivery process. Below are the temperature results of test trays comparing the Dinex
flatware to the new Aladdin flatware and Press Ganey discharge data scores for temperature for the last five
months for both campuses. We hope as Press Ganey discharge data continues to be collected in the next few
months we will continue to see a rise in our temperature scores.
Improved Hot Holding Temperatures:
Lessons Learned
Cooks had to be trained prior to implementation on how to use the new warmers to heat the
bases. The new warmers also came with some restrictions. For example, anyone with a cardiac
pacemaker cannot use them. These restrictions were communicated with the staff and regularly
followed.
The sanitation team was instructed on how to arrange the new flatware in the dish machine to
assure it is being washed, rinsed, and sanitized effectively.
The trayline team worked through how to properly arrange a tray with proper weight distribution
and appetizing visual appearance. Also, fitting the new flatware on the trays due to the diameter of
the soup bowl covers taking up extra room on the tray.
There is a one pound weight difference in the new Aladdin bases and lids compared to the Dinex
bases and lids . This had to be considered when asking our tray passers to continue delivering
them and transporting a full truck of trays. Also re-training all employees on proper lifting
techniques. The call center employees needed to be re-educated of proper ordering limits (i.e. 2
entrees max, 4 beverages, etc.) to eliminate heavy trays.
Facilities had to be involved when installing the new base warmers on the trayline. In order to
effectively utilize the small space we have, we had to move a plug and re-arrange some electrical
work to accommodate the new warming equipment.
Next Steps
Press Ganey Update:
We will continue to replace older flatware and to maintain the integrity of the Aladdin flatware by
properly using, washing, and sanitizing. This includes disseminating communication to the units to
avoid microwaving the plate bases, as over time it can deactivate the heating ability.
Explore options for cold holding flatware. This may include beverage tumblers, ice cream bowls,
and insulated salad and fruit bowls
Recycle the old Dinex tray system to other Beth Israel accounts as they are still in good working
conditions and should not be thrown out..
For more information, contact:
FoodServiceManagementWest@caregroup.harvard.edu
�
Dublin Core
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Title
A name given to the resource
Silverman Symposium
Description
An account of the resource
Each year the Silverman Symposium poster session offers BIDMC staff and affiliates the opportunity to share experiences and learn about efforts to improve Quality and Safety.
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Silverman Poster
Primary Contact
If you would like more information about this project, contact this person. Make email address clickable.
Sarah Littmann (<a href="mailto:slittman@bidmc.harvard.edu">slittman@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Food Services
Project Team
Elizabeth Haley
Brandon King
Mieka Martin
Emily Bridges
Maude Meade
Kelsey Whalen
Gary Visnick
Andre Silva
Steve Pierce
Chris Lumpkins
Shana Sporman
Chris Weiss
Michael Hanley
Chris Minette
Nora Blake
Sarah Littman
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Dublin Core
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Title
A name given to the resource
Aladdin Temp-Rite Flatware Rollout
Date
A point or period of time associated with an event in the lifecycle of the resource
2018
Format
The file format, physical medium, or dimensions of the resource
pdf
Efficiency
Environmental Sustainability
Patient and Family-Centeredness
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/c4f0bc4d64d50bfe1cac4a489f009d51.pdf?Expires=1712793600&Signature=wQgB5ThpesdwuivyLXX97kcAtVRLct6vCQeg26N0iDqAE6PpRdCqhb20032703J19B718khzhaFtqMWXNoW%7E3AwRDN%7EDErZS%7El1jrxx56fGtEJ4ATIfcLwX4QoJhKOCWVzvT9JLXWi6TNb18OCSlDnFgPFg-zkraXXFHLZ1gmCs7O-59yFGIpcTCnylZZFMDn33nRe1E%7EZE4AmQWVHUvZYJZKw9kqTrWfSkxgbBWrxGmTMWNTKIPTeHbGOTqszjMrFWv%7Ec60Vcn7fl3v5T0VAM-WuqTLvd7OHRjRG0f%7Er5qhLD-Px65egYYwdLtjuL486u5aQ5ZT804Yyx2hFTZv1Q__&Key-Pair-Id=K6UGZS9ZTDSZM
39123ce8be1dcde1e9d4e56e1a29de79
PDF Text
Text
Alicanto Consult as a clinical tool for virtual tumor boards, asynchronous dialogues and referrals across the BILH Cancer Care Network
Andrew C. Lyu, MD1; Jessica A. Zerillo, MD2,4 ;David J. Einstein, MD2; Robin Joyce, MD3; Melis Celmen, MHA4, Brian Russell, MD1;
Katherine Bloom5; Yuri Quintana, PhD5
1Department
Introduction/Problem
of Medicine, BIDMC, 2Division of Medical Oncology, BIDMC, 3Division of Hematology and Hematologic Malignancies, BIDMC, 4BID Cancer Center, 5Division of Clinical Informatics, BIDMC
Implementation and Design
With the COVID-19 pandemic and limited in-person
attendance at meetings, the Division of
Hematology/Medical Oncology saw a need to develop
and implement a clinical platform that would allow for
tumor boards to be conducted virtually. Such a platform
required the ability to easily upload, safely store,
organize and access clinical data by collaborators
across the BILH network.
At the same time, with the growth of the BILH care
network, patients have access to a wide variety of care
options, ranging from convenient community locations
with high-quality care to more specialized quaternary
care centers. Within Hematology/Medical Oncology,
patients are able to receive care close to home in their
communities and have the ability to be referred for
specialized care including clinical trials at BIDMC. To
provide the best, personalized patient-centered care,
patients are often referred from one BILH site to another.
Keeping track of patient referrals across a wide variety
of EMR systems has been a challenge with the growth
of the network.
Features and Advantages of Alicanto Consult:
Ø Allows users from all BILH sites (regardless of home EMR) to easily submit
and review clinical cases via an online interface
Ø Ability to upload, securely store, organize and access clinical data via an
online web interface or iOS application
Ø Workstation notifications via browser while logged into Consult system
Ø In-house team development team allows for customization and system
modifications to be made rapidly depending on clinical need
Ø
Ø
Ø
Aim/Goal
To develop and implement an online platform to allow
for virtual tumor boards, efficient, asynchronous clinical
discussions and electronic referrals across the BILH
cancer care network
Alicanto (https://www.alicantocloud.com) - an online platform with
tools to support group collaboration, such as web conferencing, document
sharing, and asynchronous discussion forums
Developed by Dr. Yuri Quintana and his team at the BIDMC Division of Clinical
Informatics
Alicanto BIDMC - launched in December 2019, initially to support collaborative
work across BILH within Hematology; can be accessed online at
https://www.alicantobidmc.org/ or with a mobile application.
https://apps.apple.com/al/app/alicanto-mobile/id1481350682
Ø
Ø
Alicanto Consult – part of Alicanto BIDMC; developed and preliminarily
implemented in March 2020 to support virtual tumor boards and “Difficult Cases
in Oncology COVID19 Forum”
In order to support referrals across the BILH Cancer Care Network, a pilot
program was launched in January 2021 between BIDMC and BI Plymouth
within the hematologic malignancies and genitourinary oncology disease
subgroups
Above: Alicanto Consult
Web interface
Right: Alicanto iOS mobile
application
For more information, contact:
Andrew Lyu, MD, Hospitalist, Division of Medical Oncology; alyu@bidmc.harvard.edu
�Alicanto Consult as a clinical tool for virtual tumor boards, asynchronous dialogues and referrals across the BILH Cancer Care Network
Andrew C. Lyu, MD1; Jessica A. Zerillo, MD2,4 ;David J. Einstein, MD2; Robin Joyce, MD3; Melis Celmen, MHA4, Brian Russell, MD1;
Katherine Bloom5; Yuri Quintana, PhD5
1Department
of Medicine, BIDMC, 2Division of Medical Oncology, BIDMC, 3Division of Hematology and Hematologic Malignancies, BIDMC, 4BID Cancer Center, 5Division of Clinical Informatics, BIDMC
Results/Progress to Date
Ø
(March 2020 – October 2021)
30
Ø
Total of 612 cases submitted by 62
unique users between January 2020 –
October 2021
Total of 198 users from:
–
–
25
–
20
•
•
•
•
•
•
•
•
15
10
5
<1/9/20
AJH
Atrius Health
Number
6
2
Oct
Sep
Aug
Jul
Jun
May
Apr
2020
BILH network referrals
(March 2020 – October 2021)
(March 2020 – October 2021)
14
12
10
8
6
4
2
0
Number of Submissions
4-week Rolling Average
Source: Google maps
2021
(%)
1.0%
0.3%
0.2%
1, 0%
3, 1%
17, 3%
11, 2%
13, 2%
2, 0%
GU
7, 1%
Gyn
1
BIDMC Cancer
Center
BID-Milton
558
1
0.2%
Sarcoma
BID-Needham
24
3.9%
Neuro-Oncology
BID-Plymouth
2
0.3%
LHMC
8
1.3%
MAH
10
1.6%
Key Points
Ø
Ø
13; 2%
GI
35, 6%
Beverly Hospital
91.2%
Alicanto Consult
Submissions by Type
Alicanto Consult
Submissions by Disease Group
Submissions by Location
Location
Mar
Feb
Jan
Dec
Nov
Oct
Sep
Aug
Jul
Jun
May
Apr
Mar
(blank)
0
Jan
–
BIDMC Medical Oncology
BIDMC Hematology and Hematologic
Malignancies
BILH Cancer Care network:
BID-Plymouth
BID-Needham
BID-Milton
AJH
MAH
Lahey Hospital & Medical Center
Beverly Hospital
Atrius Health
BIDMC Divisions of Radiation Oncology,
Radiology, Pathology, Surgical Oncology,
Urologic Surgery, Gynecology and more
GU Tumor Board Submissions
19
-M
ar
-2
0
19
-A
pr
-2
0
19
-M
ay
-2
0
19
- Ju
n20
19
- Ju
l-2
0
19
-A
ug
-2
0
19
-S
ep
-2
0
19
-O
ct
-2
0
19
-N
ov
-2
0
19
-D
ec
-2
0
19
- Ja
n21
19
-F
eb
-2
1
19
-M
ar
-2
1
19
-A
pr
-2
1
19
-M
ay
-2
1
19
- Ju
n21
19
- Ju
l-2
1
19
-A
ug
-2
1
19
-S
ep
-2
1
Number of new Alicanto Consult users per month
72; 12%
Tumor Board
Submissions
Ø
Thoracic
58, 9%
Breast
465, 76%
Melanoma
Hematologic
Malignancies
Other
BILH Oncology Forum for
Difficult Cases COVID 19
submissions
Next Steps
Ø
Ø
527; 86%
Referrals across BILH
sites
Alicanto Consult has allowed clinicians from across the BILH Cancer Care Network to easily submit clinical
cases for multidisciplinary review in an online, collaborative environment without the need for in-person
meetings during the COVID-19 pandemic
Through this collaboration, knowledge can be shared and brought to the patient, wherever that patient is being
cared for. When appropriate, this collaboration then encourages referrals of patients across BILH sites of care
to ensure that patients are receiving the highest quality of care, as close to home as possible
Alicanto Consult allows for efficient clinical communication, expedient clinical care, and the potential to
centralize and organize referrals from across the BILH network
Platform roll-out to additional disease subgroups interested in utilizing Alicanto
Consult for virtual tumor boards
Enrollment of additional BILH clinical care sites and disease groups to simplify
network referrals with the hope of minimizing administrative redundancies and
ultimately improving the overall clinical experience for patients across the BILH
Cancer Center network.
For more information, contact:
Andrew Lyu, MD, Hospitalist, Division of Medical Oncology; alyu@bidmc.harvard.edu
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Silverman Symposium
Description
An account of the resource
Each year the Silverman Symposium poster session offers BIDMC staff and affiliates the opportunity to share experiences and learn about efforts to improve Quality and Safety.
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Silverman Poster
Primary Contact
If you would like more information about this project, contact this person. Make email address clickable.
Andrew Lyu (<a href="mailto:alyu@bidmc.harvard.edu" target="_blank" rel="noreferrer noopener">alyu@bidmc.harvard.edu</a>)
Project Team
Andrew C. Lyu
Jessica A. Zerillo
David J. Einstein
Robin Joyce
Melis Celmen
Brian Russell
Katherine Bloom
Yuri Quintana
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Department
Any departments listed on the poster or identified in the spreadsheet.
Department of Medicine
Division of Medical Oncology
Division of Hematology and Hematologic Malignancies
BIDMC Cancer Center
Division of Clinical Informatics
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Alicanto Consult as a Clinical Tool for Virtual Tumor Boards, Asynchronous Dialogues and Referrals Across the BILH Cancer Care Network
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Format
The file format, physical medium, or dimensions of the resource
pdf
Effectiveness
Efficiency
Patient and Family-Centeredness
Timeliness
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/ff83c850a99aee13ffa7a733f8918ddc.pdf?Expires=1712793600&Signature=do8HBM4PDHgjb5WVq7TIHCkkl%7E%7EyJmaCwpcz29won35pfmEInEKGnKcJS4lR8L%7ESBEG8ZHAGlN%7EnSd6%7EanAeHbidHxnRgFCNEnTg5I6QwyqVdvOJp1lmT5NknCCR0-uK6gpgOWF2L37su98J3muyvDoMphO9p8s9FMNEfEC8bcuP4hbBhvWh6B6S0X14vwb%7EC3hDA8gmYIC7wHhxEiFnK6q%7EvQ79o95fK46SUcTPFbaRuOnnpZe1hywNjwJd4nOXiz3RZnEBfiMYZLu7qaDAjkzSXq80wmpWiHyLHjHyhOlBoUufbHdnkWjCUqPudkjkDVtJEOGbBSzldtTopGqugA__&Key-Pair-Id=K6UGZS9ZTDSZM
97407b648f0d094740f60e3a33e0b96e
PDF Text
Text
Allocation of Scare Resources Lead to Developing a Crisis Standard of Care
By Michael Cocchi, MD, Jaime Levash, and Deborah Stepanian
Beth Israel Deaconess Medical Center
Introduction/Problem
COVID-19 was spreading rapidly across the country. The number of patients coming to hospitals was
increasing at an alarming rate. Does BIDMC have enough life saving equipment? What are we going to do
if we run out of ventilators? BIDMC laid out an approach following Massachusetts Department of Public
Heath (DPH) Crisis Standards of Care (CSOC) guidelines. The goal of the CSOC is to maximize benefit to
populations of patients, often expressed as doing the greatest good for the greatest number.
Model/Indication for CSOC
As described by the National
Academies, the need for
healthcare surge capacity in a
disaster occurs along a
continuum based on demand
for health care services and
available resources.
Aim/Goal
The goal was to develop and operationalizing a fair assessment tool and efficient process for each patient
to be consistently and frequently evaluated and scored in alignment with Massachusetts DPH CSOC
guidelines.
The Team
Michael Cocchi, MD
Mary Beth Cotter, RN
Michelle Doherty, RN
Nicole Johnson, RN
Jaime Levash
Deborah Stepanian
Kimberly Voto, RN
Mary Ward, RN
The Interventions
Developed a guideline and scoring tool in alignment with state guidelines using the Sequential Organ
Failure Assessment (SOFA) in combination with patient comorbidity status.
Rolled out education on the scoring process and tool to staff conducting the assessments
Created tracking tools and reporting systems to follow patients daily to multiple times a day
Reviewed scores to determine if SOFA assessment was capturing the patient correctly
In alignment with and due to scoring methodology updates to the MA DPH CSOC, implemented
different scoring tools mid-process, shifting from evaluation/scoring related to patient comorbidity status
to a life expectancy score.
Incident demand/resource imbalance increases
Risk of morbidity/mortality to patient increases
Conventional
Contingency
Crisis
Space
Usual patient
care space fully
utilized
Patient care areas repurposed (PACU,
monitored units for ICU-level care)
Facility non-patient care areas
(classrooms, etc.) used for patient
care; Physical space no longer
available for clinical care
Staff
Usual staff called
in and utilized
Staff extension (brief deferrals of nonemergent service, supervision of broader
group of patients, change in responsibilities,
documentation, etc.)
Trained staff unavailable or unable to
adequately care for volume of
patients even with extension
techniques
Supplies
Source: Massachusetts
Department of Public Health
Crisis Standards of Care
Planning Guidance for the
COVID-19 Pandemic
Recovery
Cached and usual Conservation, adaptation, and substitution of
supplies with occasional reuse of select
supplies used
supplies
Standard of Usual care
Care
Functionally equivalent care
Normal operating
conditions
Indicator:
potential for
crisis standards
Critical supplies lacking, possible
reallocation of life-sustaining
resources
Crisis standards of care
Trigger for Crisis
Standards of Care
Along the continuum of
care, strategies to
maximize healthcare
resources include
Substitution,
Adaptation,
Conservation, ReUse
and Optimize Allocation.
OPTIMIZE ALLOCATION:
Allocate resources to
patients whose need is
greater or who are more
likely to survive the
immediate crisis.
Extreme operating
conditions
Lessons Learned
It is important to create a multidisciplinary team with strong collaboration and rapid responsiveness.
Continuous awareness of critical care resources available in a rapidly changing environment is essential .
With the introduction of daily scoring needs expected by a provider, clear communication to providers
explaining the expectations in advance is needed and embedding within their existing workflow is optimal.
Testing of the tool/process important both for feasibility but also to evaluate for risk of inequity
It is important to have a tracking tool where multiple people can be accessing and recording data
simultaneously.
Next Steps
Through monitoring of COVID-19 patient volume and availability of critical care resources, once it became
evident that supply would meet demand, the Massachusetts Crisis Standards of Care (CSOC) was
deactivated to the relief of many.
For more information, contact:
Jaime Levash, Senior Project Manager Health Care Quality
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Silverman Symposium
Description
An account of the resource
Each year the Silverman Symposium poster session offers BIDMC staff and affiliates the opportunity to share experiences and learn about efforts to improve Quality and Safety.
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Silverman Poster
Primary Contact
If you would like more information about this project, contact this person. Make email address clickable.
Jaime Levash (<a href="mailto:jlevash@bidmc.harvard.edu" target="_blank" rel="noreferrer noopener">jlevash@bidmc.harvard.edu</a>)
Project Team
Michael Cocchi
Mary Beth Cotter
Michelle Doherty
Nicole Johnson
Jaime Levash
Deborah Stepanian
Kimberly Voto
Mary Ward
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Department
Any departments listed on the poster or identified in the spreadsheet.
Health Care Quality
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Allocation of Scare Resources Lead to Developing a Crisis Standard of Care
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Format
The file format, physical medium, or dimensions of the resource
pdf
Compliance
Effectiveness
Efficiency
Equality
Safety
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/3bc8747e8f1f74802138a0f1d0095d26.pdf?Expires=1712793600&Signature=XQ0YfZSU6SHMOH5m7xDwvwK1v01Ck-zkWpR9F6IDXR9-TmM8B8-0-Hod3wJ9RgHcnmCBtjCpe8SXBQKcpJtyvx78eoceTU1MCGCEPwH1m-NMqYWO-LMpS-51MfQRUxNfE%7ECMwGvuOlKLhSY2lnSP2qjFdacLIoYGjmUjBQD2ZmA2XuYkNyaxxj%7EE9Rg0iMBvyU0a8GXlzBrtxXCSSilF31xpNcX2vX7dFZ2kpGIS0ZmAOlCRqc2kBfQ7hCXgk14iuHANVn%7EduZttLgvGVoJQ40cvAed4WUAtfrxxRrq-18tdINYEgNUJQscmBfPkfBrmnXnZN9ZKJsc48fp3UPdeFA__&Key-Pair-Id=K6UGZS9ZTDSZM
7b4e46f599997aab95ba2cd140ac7392
PDF Text
Text
Alternate Protocol for Frontal Radiographs to Assess Endotracheal Tube
Placement Improves the Confidence of Decision-Making
Liubauskas R. MD, Litmanovich D.E. MD, Chakrala N.L. MBBS, Oren-Grinberg A. MD, Eisenberg R.E. MD
INTRODUCTION
•
•
•
•
Following intubation, a frontal chest
radiograph (CXR) is obtained to
assess endotracheal tube (ETT)
position by measuring the ETT tip to
carina distance1
ETT tip location changes with neck
position, but it can be determined by
assessing the position of the mandible2
Since the mandible usually cannot be
visualized on standard CXR, we
developed a new protocol where the
mandible is seen in the CXR
We compared the confidence of
decision-making using new and
standard protocols for post-intubation
CXR to assess ETT position
WHY CARE?
•
•
An excessively distal ETT position
could lead to endobronchial intubation,
which may result in serious
complications such as3,4:
• Atelectasis of the
non-ventilated lung
• Hypoxemia, hyperinflation,
and barotrauma of the
ventilated lung with possible
development of pneumothorax
A too proximal ETT position may lead
to its displacement – caudal migration
and even self-extubation5, the
development of vocal cord injury,
resulting in permanent hoarseness and
significant airway obstruction3 and
ETT-related tracheal rupture resulting
from an overinflated ETT cuff
METHODOLOGY
Retrospective and prospective, single-center, IRBapproved study, which consisted of patients
undergoing CXR following intubation to assess the
position of the ETT-tip relative to the carina.
Two parts of the study:
• Part I- retrospectively assessed images obtained
with the standard protocol. Patients underwent a
routine supine AP post-intubation CXR for the
assessment of ETT position, in which the upper
margin of the image typically was in the lower neck
• Part II– prospectively included all consecutive CXRs
acquired using the new post-intubation protocol.
The radiology technologists palpated the mandible
to ensure that 1-2 cm of this bone would be
included within the upper margin of the image
What the heck is with the neck?
The position of the ETT depends on the
position of the neck2:
• If the neck is extended, the ETT ascends
• If the neck is flexed, the ETT descends
• Potential movement of the ETT tip can be up to
3.8 cm in cases where neck position changes
from flexed to extended or vice versa
• If the neck changes position between flexed
and neutral, or between neutral-extended, the
potential movement of the ETT tip is ~1.9 cm
In the study2,6:
• The neck is considered extended if the
mandible projects over C4 or higher
• The neck is considered neutral if the mandible
projects over C5 or C6
• The neck is considered flexed if the mandible
projects over C7 or lower
Where do we want the ETT to be?
The desired position of the ETT depending on the neck position6 (Figure 1; A, B, C):
• With the neck flexed – the ideal position of the ETT tip is 3 ± 2 cm above the carina
• With the neck neutral – the ideal position of the ETT tip is 5 ± 2 cm above the carina
• With the neck extended – the ideal position of the ETT tip is 7 ± 2 cm above the carina
We can be uncertain sometimes
We established “gray-zone” values (Figure 1) at which the
CXR are difficult to assess whether the ETT is in a satisfactory
position if the mandible is not visible:
• If the ETT tip-carina distance is >9 cm, then the ETT is too
high, regardless of the neck position
• If the ETT tip-carina distance is <1 cm, then the ETT is too
low, regardless of neck position
• If the ETT tip-carina distance is 6.0–9.0 cm, then the ETT is in
a high gray-zone position
• Rationale: if the neck is extended at the time the CXR was
obtained, the ETT is positioned appropriately. If the neck is
flexed, the ETT may move upwards with the neck in a neutral
or extended position, resulting in a too high ETT position
• If the ETT tip-carina distance is 1.0-4.0 cm - the ETT is in a
low gray-zone value
• Rationale: if the neck is flexed at the time the CXR was
obtained, the ETT would be positioned appropriately. If the
neck is extended or neutral, the ETT may potentially move
Fig. 2 – Algorithm to assess the ETT position downward, resulting in a too low position of the ETT
Making a confident decision
Algorithm for assessing the ETT position (Fig. 2):
Step 1 – is the mandible is visible on the CXR?
• If so, the position of the neck, and therefore
the ETT position, can be confidently
assessed. No additional steps
• If the mandible is not visible, go to step 2
Step 2 – is the tip of the ETT is in one of the
clear-zones?
• If so, the ETT position can be confidently
assessed regardless of the neck position
• If not, the ETT position cannot be
confidently assessed
Other times we’re sure
• Based on the “gray zones” - only when the
ETT tip-carina distance is 4.0-6.0 cm, can the
reader be confident that the ETT position is
satisfactory regardless of the neck position
• When the ETT tip-carina distance is either
>9.0 cm or <1.0 cm, the reader can be
confident that the ETT position is
unsatisfactory regardless of neck
• We established these ranges (<1.0, 4.0-6.0,
>9.0 cm) as “clear-zone” values, because
the reader can confidently recommend
moving or leaving the ETT in the current
position
Fig. 1 – Summary of different ranges of the ETT tip – carina
A – appropriate range of ETT tip when neck extended (5-9 cm)
B – appropriate range of ETT tip when neck flexed (1-5 cm)
C – appropriate range of ETT tip when neck neutral (3-7 cm)
X – Gray zone of the ETT being potentially too high (6-9 cm)
Y – Gray zone of the ETT being potentially too low (1-4 cm)
Z – Clear zone regardless of the neck position (4-6 cm)
Which zone is what now?
“GRAY ZONE” – ETT tip–carina distance, at which
it is difficult to assess whether the ETT is in a
satisfactory position if the mandible is not visible
“CLEAR ZONE” - ETT tip–carina distance, at which
the reader can confidently recommend retracting,
advancing or leaving the ETT in the current position
NB! - clear zone does not mean that the ETT position is
satisfactory, but that the reader can distinctly determine
whether the position is satisfactory or requires adjustment.
�Alternate Protocol for Frontal Radiographs to Assess Endotracheal Tube
Placement Improves the Confidence of Decision-Making
Liubauskas R. MD, Litmanovich D.E. MD, Chakrala N.L. MBBS, Oren-Grinberg A. MD, Eisenberg R.E. MD
RESULTS
•
•
•
•
There were 308 patients in the study with post-intubation CXR –
155 using the standard technique and 153 using the new protocol
Based on the mandible position, the neck was in neutral (45%;
78/173), extended (45%; 77/173) or flexed (10%;18/173) positions
There was a significant increase (p<0.001) in visualization of the
mandible on post-intubation CXR obtained with the new protocol
(92%; 141/153) compared to those with the standard technique
(21%; 32/155).
The distribution of mandible visibility and zones is summarized in
table 1 and figure 3.
ETT*
position
Certain
Standard
Protocol
32 (21%)
New
Protocol
141 (92%)
Mandible
Visible
Mandible
Clear zone 48 (31%)
7 (5%)
Not Visible Gray zone 75 (48%)
5 (3%)
Total
155 (100%) 153 (100%)
EXAMPLES FROM YOUR PRACTICE TODAY!
RESULTS
•
There were two acceptable ways to determine whether
the ETT was is in the appropriate position: by visualizing
the mandible, or by observing the ETT in the clear zone.
Combining both
measures, we
have estimated
that a confident
decision can be
made in 96.7% of
cases using the
new protocol,
compared to
51.6% of cases
using the standard
protocol (p<.001)
(Figure 4).
Table 1 Overview of
the study
results
Fig. 4 - Decision confidence rate when assessing
ETT position (new vs standard protocol)
CONCLUSION
Figure 3 - Using the standard protocol, there was an unconfident
decision rate of 48%, compared with only 3% using the new protocol.
•
When the mandible was visualized, it most commonly projected
over the C5 (32%; 56/173) or C4 (25%; 44/173) vertebral body,
with a range of C1-T2, suggesting that the neck is usually in a
neutral or slightly extended position (Figures 5 and 6).
Figure. 5 – Inaccurate interpretation of the ETT
position based on shape and angle of the
mandible. 55-year-old woman following
intubation with ETT tip 2.1 cm above the carina.
Recommendation to retract the ETT was not
made. Based solely on the shape of the
mandible, the neck may appear flexed.
Assessing by the relationship of the vertebral
body to the mandible, neck may be extended
(mandible projects over C4), introducing the risk
of ETT descending by approximately 2-4 cm
depending on neck movements, and possibly
intubating the right bronchus.
Fig. 6 – Inaccurate interpretation due to failure to
assess the relationship of the mandible to the
vertebral bodies. In this 66-year-old man following
intubation with ETT* tip 7.0 cm above the carina, it
was recommended to advance the ETT. However, in
assessing the relationship of the mandible to the
vertebral bodies, the neck appears to be in an
extended position (mandible projects over C3-C4),
making the position of the ETT appropriate, as it may
descend 2-4 cm depending on neck movements
To our knowledge, this study is the first study to
demonstrate that mandible inclusion on post-intubation
CXR is a simple and cost-effective method to ensure
proper assessment of the ETT position, sparing the
patients from unnecessary additional imaging and
almost doubling the level of certainty of the decisions
made by the radiologist.
REFERENCES
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6.
Godoy MC, Leitman BS, de Groot PM, Vlahos I, Naidich DP. Chest radiography in the ICU: Part 1, Evaluation of
airway, enteric, and pleural tubes. AJR Am J Roentgenol. 2012;198(3):563-71.
Conrardy P, Goodman L, Lainge F, Singer M. Alteration of endotracheal tube position. Flexion and extension of
the neck. Crit Care Med. 1976;4(1):8-12.
Mathew R, Alexander T, Patel V, Low G. Chest radiographs of cardiac devices (Part 1): Lines, tubes, non-cardiac
medical devices and materials. SA J Radiol. 2019;23(1):1729.
Owen RL, Cheney FW. Endobronchial intubation: a preventable complication. Anesthesiology. 1987;67(2):225-7.
Kearl RA, Hooper RG. Massive airway leaks: an analysis of the role of endotracheal tubes. Crit Care Med.
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6. Goodman L, Conrardy P, Laing F, Singer M. Radiographic evaluation of endotracheal tube position. AJR Am J
Roentgenol. 1976;127(3):433-4.
�
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Silverman Symposium
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Each year the Silverman Symposium poster session offers BIDMC staff and affiliates the opportunity to share experiences and learn about efforts to improve Quality and Safety.
Date
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2021
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Rokas Liubauskas (<a href="mailto:rliubaus@bidmc.harvard.edu" target="_blank" rel="noreferrer noopener">rliubaus@bidmc.harvard.edu</a>)
Project Team
Rokas Liubauskas
Diana Litmanovich
Nahara Chakrala
Achikam Oren-Grinberg
Ronald Eisenberg
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Alternate Protocol for Frontal Radiographs to Assess Endotracheal Tube Placement Improves the Confidence of Decision-Making
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2021
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