2
20
1687
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https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/0777f7d7eba4f50ffd56929296e54324.pdf?Expires=1712793600&Signature=hPJ06UbDLtMw1Iqz0fgncBQ-Df9CzHPgiGxUm7trJAd9F-D9nNzzuAEXkSnjHinqzxGv6P5TaQAOv5rk5D00RuN-CmubPU8KJvt9RK-7C-Tt2%7EMmxxNTbxGx6UaKVt9MqVZNqu%7Eb4UotvqNufj%7EiYsZNoJ3YziwUS8NyBPBx02Tgq5r0OFRpzxiz2V%7E1jfV85Ppoz-tw5qdS2oWbmfgjEbSP6ANP5oBKKehtB2Ab%7EbPUBsv1PyJEYMhHxnmv6QSqmvbqxjsEs9K8GhRhvZliD7Cdj4hFfhDe32f25kiBTSuyqhlbYQyFoiVWUnuz2GVHtN1QYPtSB5Aa%7ECXzsrejXw__&Key-Pair-Id=K6UGZS9ZTDSZM
17be930de2a04b14b812b000962ab16c
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Basic Research Response during the COVID-19 Pandemic
Andi Hernandez, Vice President, Tanya Santos, Director, and Kim Chun, Project Manager, Research Operations
Beth Israel Deaconess Medical Center
Introduction
In March 2020, the City of Boston declared COVID-19 a public health emergency.
Research Operations was tasked with safely shutting down basic and translational research labs
by instituting new operational protocols and best practices. Only essential research and
maintenance staff were allowed on-site and all non-essential research work was transitioned to
remote. In facilitating the Research shutdown, we recognized the potential in improving our
operational and communications plan for reopening the Research labs in June 2020.
Goal
Our overall goal was to effectively shut down and reopen basic and translational research labs
while ensuring the safety of all Research Employees and animals and regularly communicating
progress with the Research Community.
The Team
Leadership
Gyongyi Szabo, MD, PhD; Chief Academic
Officer, BIDMC and BILH
Andi Hernandez, Vice President, Research
Operations
Research Operations
Tanya Santos, Director, ResOps
Kim Chun, Project Manager, ResOps
Barbara Garibaldi, Director, ARF
Denise Glass, Assoc. Director, ARF
Mark Varhol, Lead Project Manager, ResFac
Lucero Vega, Sr. Project Manager, ResFac
Kim Tablante, Research Administration
Chris Botte, Academic Research Computing
Environmental Health & Safety
Kristin Piticco, Interim Director
Peter Schooling, Safety Officer
Rob Griffin, Biosafety Officer
Research Reopening Planning Committee
Al Charest, PhD, Research Safety
Committee Chair
Steven Balk, MD, PhD – Professor of
Medicine
Jack Lawler, PhD, Professor of Pathology
Leo Otterbein, PhD, Professor of Medicine,
IACUC Chair
Evan Rosen, MD, PhD, Principal Investigator
The Interventions
Interventions in preparation for Research Shutdown
Generated Lab Ramp-Down Checklist, Remote Access to Systems tools for Research Community
Work from Home Assessment/Staffing Survey distributed
Managed the process for research lab donations for Clinical Supply shortages
Managed Redeployment to COVID-19 clinical efforts
Delayed New Hires/Visa Processing
Kept abreast of changing NIH Grant Management guidelines
Continued on-site management/maintenance of labs by Research Facilities
Converted research lab space to Clinical COVID-19 testing and PPE reprocessing facilities
Interventions in preparation for Phased Research Reopening
Hosted Town Hall meetings regularly (2x per month from April 2020 to July 2020) to update Research
Community
Organized a Research Reopening Planning Committee comprised of members of leadership,
Research Operations, EH&S, and Research Community leaders
Discussed and Coordinated timing of Reopening with: BIDMC COVID-19 Command Center, Harvard
University Committee of Research Laboratory Re-Entry, Conference of Boston Teaching Hospitals
group & AAMC Dean’s group
Created a Reopening Survey for completion by the Research Community to obtain feedback about
their safety concerns with returning to the lab
Implemented the Section Chiefs Program to assist in COVID-19 Safety efforts during Reopening
Created the Research Reopening Resources Page on the BIDMC Portal
Created and implemented myPATH Return to Research Training for all returning staff and new
incoming staff during Phase I and Phase II
Produced Research tools: example: checklists, signage, and put engineering controls in place for
social distancing
Opened a direct e-mail line for Return-specific questions: researchreturn@bidmc.harvard.edu
For more information, contact:
Tanya Santos, Director, Research Operations: msantos3@bidmc.harvard.edu
�Basic Research Response during the COVID-19 Pandemic
Andi Hernandez, Vice President, Tanya Santos, Director, and Kim Chun, Project Manager, Research Operations
Beth Israel Deaconess Medical Center
Basic Research Shutdown Timeline
March 15
(Sunday)
Communication
from CAO re:
Shutdown
Preparations for
Shutdown
March 16
(Monday)
• COVID-19
Redeployment
• Animal Welfare
• Essential
Staffing
March 17
(Tuesday)
Guidelines and
Safety Protocols
created and
provided to
Research
Community
March 18
Wednesday
Results
• Staffing Survey Completed
• Remote Work Assess
Guidelines Distributed
•
~118 Labs Shutdown
by 5pm in 3 Research
Buildings
1. Basic Research labs and core facilities were shut down by 5:00pm on March 18, 2020. As shown by
the graphic above, Research was successful in shutting down labs within a 3-day period.
Basic Research Reopening Phased Approach
55 out of 99 Research
employees redeployed
Due to supply shortages,
Laboratory supplies/PPE
donated for clinical needs
Lab Spaces were made available for
COVID-Testing and Masking
Stations while not in use
3. During the Research shutdown, the Research Community contributed to BIDMC’s overall COVID-19
management effort by diverting personnel assistance, supplies, and lab spaces.
Section Chiefs have been identified for larger
open lab units on each floor/section. They are
responsible for coordinating and creating
schedules for shared equipment use and
common areas for eating/breaks as well as
addressing issues and concerns with COVID19 prevention processes.
COVID-19 Safety Officers are responsible for
reporting any concerns with processes within
the lab or shared spaces to Section Chiefs,
appropriately coordinating with the PI
2. Our phased reopening model for Research enables us to adjust on-site research/population density
phase by phase easily with as little disruption as possible. In June 2020, we entered Status Yellow
(Phase I) and after one month, we ramped up to Status Blue (Phase II). The triggers for our gradual
ramp up/down are guided by BIDMC and state and local response to any COVID-19 trends.
4. The Section Chiefs program (~35 individuals) significantly supported and contributed to the Research
Operations team’s effort to safely reopen basic research labs. The Section Chiefs were our “eyes” on the
research floors. They aided in enforcing safety best practices and communicating guidelines to
Researchers.
For more information, contact:
Tanya Santos, Director, Research Operations: msantos3@bidmc.harvard.edu
�Basic Research Response during the COVID-19 Pandemic
Andi Hernandez, Vice President, Tanya Santos, Director, and Kim Chun, Project Manager, Research Operations
Beth Israel Deaconess Medical Center
More Results
5. Throughout the shutdown and reopening period, Research Operations communicated regularly with
the Research Community via virtual Research Town Halls and by re-distributing BIDMC-wide e-mails to
the Research Community highlighting Research-specific instructions/relevance. Town Halls were
recorded and made available on the Portal to ensure everyone had access to the updates. Over the
course of this period, we also generated a number of tools and resources for our Researchers.
Lessons Learned
Researchers want to be heard and are willing to provide feedback
Efforts need to be coordinated with all key stakeholders in order for implementation of new guidelines
to be successful and met with little resistance
Research now has an emergency management contingency plan and a catalogue of tools available
that can be tailored to based on the severity of the situation
Research Operations opened more direct lines of communication & reach to our Research
Community through the implementation of the Section Chiefs program (in addition to our existing Lab
Safety Officer Program)
Next Steps
Continue to monitor/evaluate emergency management contingency plan
Improve tools and resources already available and connect these to the appropriate contingency
levels (See Results #2)
Re-enforce awareness of the available tools and resources contingency plans
Better utilize available resources to strengthen communications with Research Community (Portal,
use of pre-existing templates, distribution lists)
For more information, contact:
Tanya Santos, Director, Research Operations: msantos3@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.
Tanya Santos (<a href="mailto:msantos3@bidmc.harvard.edu" target="_blank" rel="noreferrer noopener">msantos3@bidmc.harvard.edu</a>)
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Gyongyi Szabo
Andi Hernandez
Tanya Santos
Kim Chun
Barbara Garibaldi
Denise Glass
Mark Varhol
Lucero Vega
Kim Tablante
Chris Botte
Kristin Piticco
Peter Schooling
Rob Griffin
Al Charest
Steven Balk
Jack Lawler
Leo Otterbein
Evan Rosen
Department
Any departments listed on the poster or identified in the spreadsheet.
Leadership
Research Operations
Environmental Health & Safety
Research Reopening
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
Basic Research Response During the COVID-19 Pandemic
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
Safety
Timeliness
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/d1101a8db809d083100a9e78481b5cc5.pdf?Expires=1712793600&Signature=ndiBrq0XOQ02dCHpz9SYsHrZ8EiWl%7EBXKuBEVA0nNbaeHBFFpelnsBLwbmzVmj9Dubr6SwnAbMuy34gRUTpDKbAF2vLmmqHzYrvkMTHbykXPsR3GZUC4kxBlzGBk8q49-ELvp1xUOf5NYK-wYAgSIji9Svy5ACzuvjKSVcT1FvDWqLayRhfhynQ6ZPeR3TZ98eyrqKUU%7E18F2DaIwp3ipIEsBUNDIAFeYP64WZA2fVEZsSkDBLG%7ES9JBJIq1rl7NoBu-0IgvH49WPoQOv7txeeMIq1x--lYt1qV9jkGqM1KDDUJeyIydOCFBIhzPCRQPkCA3KSAoupQ1wNWeujJBmw__&Key-Pair-Id=K6UGZS9ZTDSZM
37f1a16237a76043e971634f7a6c911a
PDF Text
Text
Providing Organized Knowledge in Chaotic Times:
Creating a Virtual Exam Room Drawer for HCA
Daniel Z. Sands, MD, MPH
Harvard Medical School, Division of General Medicine, HealthCare Associates
Background
•
•
•
•
•
•
HCA is a large complex primary care practice at BIDMC
40,000+ patients with ~100,000 visits/year by 60+ MDs
and NPs and 100+ residents with embedded mental health
and support services
Most resources printed and available only on-site (Fig. 1)
In March 2020 in-person visit volume dropped rapidly as
clinicians stayed home and the practice transitioned to
virtual visits → no access to printed info or colleagues
Rapidly evolving policies, procedures, and protocols
related to new care models and COVID distributed via email, some available (with delay) on the BIDMC portal,
HMFP website, BILH website, BIDMC’s public website, or
elsewhere
As a result, needed info not available (Fig. 2)
Approach
Results
Author created a web portal for internal use, HCAportal.net (Fig. 3)
Quick, easy, not password-protected, easily usable on mobile devices and off-site
Search functionality to make it easy to rapidly find resources
Uniform look and feel throughout
Rapidly and easily updates from any location
Platform initially WordPress with Google for document management
Content:
• Internal documents and databases and some links to external
• Created database of personal fax numbers that was user-updated
• COVID-related documents
• Telehealth education
• No PHI or other confidential information permitted (no password protection)
• Editing and curation:
• Initially by one person (poster author), which proved inefficient and burdensome
• Later created federated authoring/editing using Google Apps, so key stakeholders could control content
and organization for designated sections of portal (Fig. 4)
• Author (exec editor) responsible for educating and onboarding, as well as promulgating style standards
• Platform evolution:
• Wanted simpler editor, search function, and platform
consolidation, so migrated to Google Sites
• Content evolution:
• Many other resource needs identified
• Added many useful resources from exam rooms
transitioned to digital formats
• Expanded to include new tools and resources, including
directories, referral guidelines, billing resources, and
conference handouts
• Editorial/curation evolution:
• Single editor proved inefficient and burdensome
• Created federated authoring/editing, so key
stakeholders could control content and organization of
sections of portal (Fig. 4)
• Author responsible for educating and onboarding, as
well as promulgating style standards
• Onboarding starts with “Helping” page on portal
• ~500 website uses per week at peak
•
•
•
•
•
•
•
Figure 1: Printed Info in HCA Exam Rooms
Rapidly
changing
information
No casual
interactions
Clinicians
not in
practice
Info not
available
when and
where it's
needed
Discussion
Webmaster &
Executive
Editor
Administrative
Editor
Multiple
distribution
channels
Info pwprotected or
not mobilefriendly
Figure 2: Factors leading to info gaps
Section Editor
1
Figure 3: HCAportal.net
Search function
Editor identified on each page
Info and training for editors
Section Editor
2
Section Editor
3
Figure 4: Federated Authorship Model
• Pandemic highlighted inefficiencies in access to info
resources in HCA à encouraged innovation
• Although started with COVID and remote-care related
resources, through faculty feedback we identified many
other needs
• Federated authorship model key to sustainability
• Online resources make it possible to practice virtually
• The portal has allowed us to think differently about tools
and resources we use in HCA
• The portal remains in heavy use and continues to expand
in scope
• HCA Portal can serve as a model for other clinical divisions
�
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.
Daniel Z. Sands (<a href="mailto:dsands@bidmc.harvard.edu" target="_blank" rel="noreferrer noopener">dsands@bidmc.harvard.edu</a>)
Department
Any departments listed on the poster or identified in the spreadsheet.
Division of Medicine
Healthcare Associates
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Daniel Z. Sands
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
Providing Organized Knowledge in Chaotic Times: Creating a Virtual Exam Room Drawer for HCA
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
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/93c5a805a2c7d409d11fce186a16266a.pdf?Expires=1712793600&Signature=opX%7EGD--KmTMFGy8e4%7EsuQTNsRLtA27sT1CgIMXpCEHemBteh8c7NrGjspjCdyO%7EQQ6Z%7E8ufxfKw9BYTLUI5PfguUUl5SQh5QV-ud633dPuwk%7E9T5K-Lxf%7ErAoY5vMBZKayObcDLir9xQuiM8Wzolx6W35enaHoA-%7E1SLH2bzyzvfJwLrtIgcaDLFQt-zHsKqMwHm%7E2SoYclgEQdvGoJR8j%7EtdqsmDHxcInR-yKHlfGVNjaehUnvbu5Xuyvl9-jMyWTNCsBlB9%7EHn-gHKOCUw74HZYHwjVf%7E0BjVe--%7EQf8IjV8tGeV%7EDOwd4fMuAPEkiNs9clIz7wGWKUJrqgAV-w__&Key-Pair-Id=K6UGZS9ZTDSZM
45e2b6b7b407e27bbd58b2e7b8c8b5c2
PDF Text
Text
CLOSED: Closing Loops by Operationalizing Systems Engineering and Design
Talya Salant1, James Benneyan2, Nicole Nehls2, Mark Aronson3, Scot Sternberg3, Gordon Schiff4,5, Russell Phillips3,5, Maria Rivera, DeeDee O’Brian, Meghan Dreilak
1
Bowdoin Street Health Center, Beth Israel Deaconess Medical Center, 2Healthcare Systems Engineering Institute, Northeastern University, 3Division of General Medicine, Beth Israel Deaconess Medical Center,
4
Center for Patient Safety, Brigham and Women’s Hospital, 5Center for Primary Care, Harvard Medical School
Motivation
Objective
• Diagnostic errors in primary care are costly and often are due to failures to follow
up (“close the loop”) on diagnostic tests, referrals, and symptoms
(1) Diagnostic tests and referrals often are not completed
(2) Tests and referral results often are not communicated to patients and PCPs
(3) PCPs frequently are not informed when symptoms evolve, altering diagnosis
• Methodical systems approach to closing loops on diagnostic processes will
measurably improve timely completion from approximately 70% to 90%
Aim to reduce diagnostic errors using systems engineering methods to 1) redesign diagnostic processes (diagnostic testing, specialist
referrals, and symptom monitoring) in primary care and 2) develop highly reliable and generalizable, “closed loop” systems
•
•
•
•
•
•
Conceptual Framework of Project
•
•
•
•
•
•
2021
Problem Understanding
2022
Solution Design & Testing
2024
2023
Solution Implementation
Impact Evaluation
Results
Methods
Problem Understanding
Data analysis of loop closure rates,
timeliness, and disparities
Statistical process control charts to
evaluate stability of process performance
Process mapping using Lean, human
factors, and reliability concepts
Failure Modes Effect Analysis (FMEA) and
Fault Tree Analysis (FTA)
Chart reviews and patient interviews
Simulation modeling of “loop of loops”
2020
Solution Design & Testing
Structural Analysis Design Technique for
design and ideation
Participatory patient-centered design
Quality improvement and health services
research approaches
Process improvement and redesign
Pilot testing and prototyping using
reliability design science concepts
Simulation modeling to evaluate
interventions and impact
•
•
•
•
Loop closure rates and timeliness of loop closure varies significantly based on the department and test site
Process maps highlighted areas most susceptible to failures and in most need of intervention and extra support
Failure analyses emphasized the severity and frequency of the failures identified in the process mapping stage
Structural analysis design technique diagrams and reliability design science concepts helped facilitate process redesign brainstorming
and new thinking which resulted informed potential solutions and pilot tests
SPC Charts
Process map
Rapid cycle pilot testing
Reliability Science Design Pyramid
High reliability
Low reliability
SADT Diagram
For more information, contact:
�CLOSED: Closing Loops by Operationalizing Systems Engineering and Design
Talya Salant1, James Benneyan2, Nicole Nehls2, Mark Aronson3, Scot Sternberg3, Gordon Schiff4,5, Russell Phillips3,5, Maria Rivera, DeeDee O’Brien, Meghan Dreilak
1
Bowdoin Street Health Center, Beth Israel Deaconess Medical Center, 2Healthcare Systems Engineering Institute, Northeastern University, 3Division of General Medicine, Beth Israel Deaconess Medical Center,
4
Center for Patient Safety, Brigham and Women’s Hospital, 5Center for Primary Care, Harvard Medical School
Lessons Learned
•
•
•
•
•
General
Systems engineering approaches have proven to be useful to study complex problems in
healthcare and improve and redesign care processes and outcomes
Improvement of loop closure rates in clinical domains that were heavily impacted by COVID will
have direct clinical and cost benefits
Incorporated equity as a key dimension of quality within our systems engineering will optimize
the generalizability and universality of our proposed systems redesign
Our model of collaboration, which integrates the perspectives of patient advisors, staff, and
experts from disciplinary fields both within and outside clinical care prompts us to be more
innovative and pragmatic
Our multidisciplinary approach to patient safety and quality may serve as a model for future
work in systems redesign
•
•
•
•
•
•
•
•
Solution Design & Testing
Need to consider patient diagnostic and care journey through the loop of loops
Need to find right balance of effort vs reward: Is the juice worth the squeeze?
Higher reward with focusing efforts on upstream processes (efficient, timely scheduling and patient
education) rather than further downstream (rescheduling after DNKAs)
Important to have primary processes that prevent failures for majority (~80%) of patients and
secondary processes to detect failures
Need reliable mechanisms and processes to detect and mitigate for patients with loops not closed
Processes and solutions should put emphasis on patients that providers are actually concerned about
(to reduce staff burden and information overload)
Need to generate more “out of the box” ideas that are still practical given constraints and priorities of
system
Need to operationalize and align sense of urgency between providers and patients
Publications
Benneyan J, White T, Nehls N, Yap T, Aronson M, Sternberg S, Anderson T, Goyal K,
Lindenberg K, Kim H, Cohen M, Phillips R, Schiff G (2020). Systems analysis of a dedicated
ambulatory respiratory unit for seeing and ensuring follow-up of patients with COVID-19
symptoms, Journal of Ambulatory Care Management, in publication. ID: NIHMS1714749
Nehls N, Yap T, Salant T, Aronson M, Schiff G, Olbricht S, Reddy S, Sternberg S, Anderson T,
Phillips R, Benneyan J (2021), Systems Engineering Analysis of Diagnostic Referral Closed
Loop Processes, under review
•Radiology paper under review
What is Systems Engineering?
•
Systems engineering is a structured approach and set of methods to methodically analyze,
design, and optimize effective processes that perform robustly and with high reliability
•
Different and complementary to traditional quality improvement and strongly advocated by the
Institute of Medicine, NIH, and others.
Includes human factors, process and failure analysis, design concept generation, rapid
prototyping, process design, reliability engineering, computer modeling, and systems
integration methods.
AHRQ’s Patient Safety Learning Labs grants are funded to integrate systems engineering in
patient safety initiatives.
For more information or assistance with systems engineering: www.hsye.org
•
•
•
For more information, contact:
Talya Salant, MD, Medical Director Bowdoin Street Health Center, tsalant@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.
Tayla Salant (<a href="mailto:tsalant@bidmc.harvard.edu" target="_blank" rel="noreferrer noopener">tsalant@bidmc.harvard.edu</a>)
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Community Health Center
Project Team
Talya Salant
James Benneyan
Nicole Nehls
Mark Aronson
Scot Sternberg
Gordon Schiff
Russell Phillips
Maria Rivera
DeeDee O’Brian
Meghan Dreilak
Department
Any departments listed on the poster or identified in the spreadsheet.
<p>Bowdoin Street Health Center, Beth Israel Deaconess Medical Center</p>
<p>Healthcare Systems Engineering Institute, Northeastern University</p>
<p>Division of General Medicine, Beth Israel Deaconess Medical Center</p>
<p>Center for Patient Safety, Brigham and Women’s Hospital</p>
<p>Center for Primary Care, Harvard Medical School</p>
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
CLOSED: Closing Loops by Operationalizing Systems Engineering and Design
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
Safety
Timeliness
-
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
PDF Text
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
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Title
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Addressing the Gap in NAFLD Screening
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
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The file format, physical medium, or dimensions of the resource
pdf
Compliance
Effectiveness
Efficiency
Patient and Family-Centeredness
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75752262bdb033bcbea59d0776080417
PDF Text
Text
Handoff Redesign to Reconnect and Reduce Burnout
Mitchell Ross MD, Susan McGirr MD, Justine Blum MD, Rachel Hensel MD, Alicia Clark MD
Division of General Medicine, Section of Hospital Medicine
Introduction
Handoffs between Hospitalists going off
and coming onto service are frequent.
Our prior process involved extensive
written communication through multiple
overlapping documents but did not
require any verbal exchange. Burnout
from a cumbersome written process was
exacerbated by COVID-19, which also
made it more difficult for colleagues to
converse. By modifying the service
signout process, we aimed to improve
efficiency and reduce burnout
without sacrificing Hospitalist
preparedness to assume patient care.
Methods
First, Hospitalists were openly invited to
discuss the current signout process,
identify major problems, and offer
possible solutions. All Hospitalists were
sent baseline surveys, to which 47
responded. Based on the themes
generated, we proposed a modified
process abbreviating much of the
written communication and adding a
30-60 minute verbal handoff. This
modified process was then piloted over a
four-week period among all Hospitalists
providing direct patient care on the 12
Reisman medical unit. Participating
providers were surveyed after both giving
and receiving handoffs. 10-13 responses
were generated per question.
Pre-Intervention Survey
Effective Use of Time (Offgoing)
Post-Intervention Survey
Effective Use of Time (Offgoing)
Strongly disagree
(11%)
Disagree (49%)
Strongly disagree
(8%)
Disagree (15%)
Neither agree nor
disagree (4%)
Agree (32%)
Neither agree nor
disagree (0%)
Agree (39%)
Strongly agree (4%)
Strongly agree (39%)
Effective Use of Time (Oncoming)
Strongly disagree
(0%)
Disagree (10%)
Neither agree nor
disagree (17%)
Agree (62%)
Neither agree nor
disagree (0%)
Agree (50%)
Strongly agree (8%)
Strongly agree (40%)
A lot less (23%)
Neither agree nor
disagree (11%)
Agree (43%)
About the same
(8%)
More (15%)
Figures 1-3. Survey responses regarding preexisting signout process. N=47.
More providers (77% vs. 36%) felt
the piloted signout process was an
effective use of time.
•
Reduced estimated time by 12
minutes per patient.
•
90% of oncoming providers felt
prepared to start after receiving a
verbal handoff with an abbreviated
written signout.
•
The majority of providers (6970%) preferred the modified
signout process.
•
77% of providers going off service
indicated the piloted process was
“less” or “a lot less” likely to
contribute to burnout.
Opportunities
Likely to Contribute ___ to Burnout
Strongly disagree
(2%)
Disagree (9%)
Strongly agree
(36%)
•
Effective Use of Time (Oncoming)
Strongly disagree
(2%)
Disagree (11%)
Contributes to Personal Burnout
Key Results
Less (54%)
A lot more (0%)
Figures 4-6. Survey responses regarding
piloted signout process. N=10-13.
•
Improved human connection
•
Collaborative learning
•
Peer to peer feedback
Next Steps
•
Implementation on all direct care
(Attending only) services.
•
Incorporate verbal handoff into
teaching service signout.
�Handoff Redesign to Reconnect and Reduce Burnout
Mitchell Ross MD, Susan McGirr MD, Justine Blum MD, Rachel Hensel MD, Alicia Clark MD
Division of General Medicine, Section of Hospital Medicine
Introduction
Handoffs between Hospitalists going off
and coming onto service are frequent.
Our prior process involved extensive
written communication through multiple
overlapping documents but did not
require any verbal exchange. Burnout
from a cumbersome written process was
exacerbated by COVID-19, which also
made it more difficult for colleagues to
converse. By modifying the service
signout process, we aimed to improve
efficiency and reduce burnout
without sacrificing Hospitalist
preparedness to assume patient care.
Methods
First, Hospitalists were openly invited to
discuss the current signout process,
identify major problems, and offer
possible solutions. All Hospitalists were
sent baseline surveys, to which 47
responded. Based on the themes
generated, we proposed a modified
process abbreviating much of the
written communication and adding a
30-60 minute verbal handoff. This
modified process was then piloted over a
four-week period among all Hospitalists
providing direct patient care on the 12
Reisman medical unit. Participating
providers were surveyed after both giving
and receiving handoffs. 10-13 responses
were generated per question.
Pre-Intervention Survey
Post-Intervention Survey
Average 37 Minutes per Patient
Average 25 Minutes per Patient
>60 (20%)
>60 (15%)
50-60 (7%)
50-60 (0%)
40-50 (4%)
40-50 (8%)
30-40 (26%)
30-40 (15%)
20-30 (30%)
20-30 (31%)
10-20 (13%)
10-20 (23%)
0-10 (0%)
0-10 (8%)
0
5
10
Key Results
15
0
1
2
3
4
5
Figure 7. Estimated time per patient completing entire
signout process. N=47. Typical census of 8 patients = 5
hours.
Figure 8. Estimated time per patient completing entire
signout process. N=13. Typical census of 8 patients = 3.5
hours.
Things Fall Between the Cracks
Important Missed Information
FREQUENTLY (9%)
•
More providers (77% vs. 36%) felt
the piloted signout process was an
effective use of time.
•
Reduced estimated time by 12
minutes per patient.
•
90% of oncoming providers felt
prepared to start after receiving a
verbal handoff with an abbreviated
written signout.
•
The majority of providers (6970%) preferred the modified
signout process.
•
77% of providers going off service
indicated the piloted process was
“less” or “a lot less” likely to
contribute to burnout.
NO (50%)
Opportunities
SOMETIMES (47%)
NOT SURE (30%)
INFREQUENTLY (45%)
YES (20%)
0
5
10
15
20
Figure 9. Estimated frequency of missed
information with pre-existing signout process.
N=47.
25
•
Improved human connection
•
Collaborative learning
•
Peer to peer feedback
Next Steps
0
2
4
Figure 10. Oncoming providers’ report of later
discovered important information not covered
with modified signout. N=10.
6
•
Implementation on all direct care
(Attending only) services.
•
Incorporate verbal handoff into
teaching service signout.
�Handoff Redesign to Reconnect and Reduce Burnout
Mitchell Ross MD, Susan McGirr MD, Justine Blum MD, Rachel Hensel MD, Alicia Clark MD
Division of General Medicine, Section of Hospital Medicine
Introduction
Handoffs between Hospitalists going off
and coming onto service are frequent.
Our prior process involved extensive
written communication through multiple
overlapping documents but did not
require any verbal exchange. Burnout
from a cumbersome written process was
exacerbated by COVID-19, which also
made it more difficult for colleagues to
converse. By modifying the service
signout process, we aimed to improve
efficiency and reduce burnout
without sacrificing Hospitalist
preparedness to assume patient care.
Methods
First, Hospitalists were openly invited to
discuss the current signout process,
identify major problems, and offer
possible solutions. All Hospitalists were
sent baseline surveys, to which 47
responded. Based on the themes
generated, we proposed a modified
process abbreviating much of the
written communication and adding a
30-60 minute verbal handoff. This
modified process was then piloted over a
four-week period among all Hospitalists
providing direct patient care on the 12
Reisman medical unit. Participating
providers were surveyed after both giving
and receiving handoffs. 10-13 responses
were generated per question.
Provider Preparedness and Preferences
Key Results
Felt Prepared to Start on Service
Strongly disagree
(0%)
Disagree (10%)
Neither agree nor
disagree (0%)
Agree (40%)
•
More providers (77% vs. 36%) felt
the piloted signout process was an
effective use of time.
•
Reduced estimated time by 12
minutes per patient.
•
90% of oncoming providers felt
prepared to start after receiving a
verbal handoff with an abbreviated
written signout.
•
The majority of providers (6970%) preferred the modified
signout process.
•
77% of providers going off service
indicated the piloted process was
“less” or “a lot less” likely to
contribute to burnout.
Prefer Verbal Signout (Offgoing)
Strongly agree (50%)
Figure 11. Oncoming providers’ perceived
preparedness after receiving modified signout. N=10.
Yes (69%)
Not Sure (8%)
Prefer Verbal Signout
(Oncoming)
Yes (70%)
Not Sure (20%)
No (23%)
Figure 13. Offgoing providers’ preferences for or
against modified signout. N=13.
Opportunities
•
Improved human connection
•
Collaborative learning
•
Peer to peer feedback
No (10%)
Figure 12. Oncoming providers’ preferences for or
against modified signout. N=10.
Next Steps
•
Implementation on all direct care
(Attending only) services.
•
Incorporate verbal handoff into
teaching service signout.
�Warm Handoff Guidelines
SHOULD
SHOULD NOT
Focus on the most complex patients
Simply repeat information already written
Express uncertainty: what’s unknown
and/or undifferentiated
Explain deviation from standard of care
Read directly from abbreviated written
signout without adding context
Require the receiver to take notes
Include questions and clarifications
Be a one-way or lopsided conversation
Mention nuanced social issues
Be rushed or inconveniently timed
Ideally occur with medical record in view
Last more than an hour in most cases
Identify follow up communication needed
�
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Title
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Handoff Redesign to Reconnect and Reduce Burnout
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
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PDF
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.
Mitchell Ross (<a href="mailto:mwross@bidmc.harvard.edu" target="_blank" rel="noreferrer noopener">mwross@bidmc.harvard.edu</a>)
Project Team
Mitchell Ross
Susan McGirr
Justine Blum
Rachel Hensel
Alicia Clark
Department
Any departments listed on the poster or identified in the spreadsheet.
Medicine
Hospital Medicine
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
Handoff Redesign to Reconnect and Reduce Burnout
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
Safety
Timeliness
-
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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
1.
2.
3.
4.
5.
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.
1993;21(4):518-21.
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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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
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Primary Contact
If you would like more information about this project, contact this person. Make email address clickable.
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
Department
Any departments listed on the poster or identified in the spreadsheet.
Radiology
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Title
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Alternate Protocol for Frontal Radiographs to Assess Endotracheal Tube Placement Improves the Confidence of Decision-Making
Date
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2021
Format
The file format, physical medium, or dimensions of the resource
pdf
Effectiveness
Efficiency
Safety
Timeliness
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https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/3ef6f52c68111d35033bb010b8e189c3.pdf?Expires=1712793600&Signature=AvLsU5rC%7E6FRL%7EoRoiqdf99DPZdgeZOVZdkLdpDYMRYlnxfGdgU9WEVv4-RXvuv2ecH2i8xH5QO-wgvVyQ74GaXGeTkHZrrv-GZ7GAsVdodk3ZLo%7EEWzahfYGF2H5cJ1Pup1Sb8qzbIVWvpUgBksJOYYCIlRKDpXkvpngqIensa2Usf0Ov5uHcKbwUuLVZ4GwZz8FVobkeZoSdCNw-qKp-nLLPoxG6%7EuisRCgC%7EJh5tlqbmk2PWCe8PScw1sowHKkVZ1fTbUepM5u5lSVs09HofjogTNQhwYjhDvcFJ8-2i6xkWla6Oqe0mG472neOaCVmIRGQkgwdYGZ6awR15nVQ__&Key-Pair-Id=K6UGZS9ZTDSZM
ef8016f83c23c61c81d3f3c0b98ddffe
PDF Text
Text
"I Got the Shot: The Story of COVID Vaccine Clinics in the Community"
Ellen Volpe, Kristin O’Reilly, Katelyn Rick, Jordan Ellis, Jaime Levash, Jasmine Cline-Bailey
BIDMC
Results/Progress to Date
Introduction/Problem
Total Doses given by BIDMC
47672
Axis Title
In December of 2020, nearly one year into a global pandemic that had killed over
300,000 Americans the world was looking for something to be hopeful about. On
December 13, 2020 Pfizer Biotech received the initial EUA approval for a two
dose COVID-19 Vaccine that had promising results in clinical trials. Shortly
thereafter Moderna and J&J were also approved and BIDMC’s mission shifted to a
widespread vaccination campaign.
31109
Aim/Goal
The goal of this work was to provide access to life saving vaccines to as many
patients as possible and focus our efforts on the communities where our patients
were disproportionately impacted by the pandemic.
14926
The Interventions
Reviewed data that showed where the highest concentration of COVID cases were by zip
code
Worked with facilities to identify potential clinic locations in those areas: Dorchester, Chelsea,
Boston
Our IT team developed a worklist of our patients based on eligibility criteria
We used that email/ text patients directly to schedule their appointment
Outlined a process for how the clinic would flow: outreach, scheduling, perform check in,
documentation, and future scheduling
Outlined safety protocols for vaccine sites with multiple vaccine types
Created staffing and throughput models to maximize capacity
Recruit, train, and staff each location
Strategized to ensure we used an equitable approach to outreach, scheduling, booking, and
administering of vaccines
Engaged with Interpreter Services to ensure we were adequately serving our LEP patients
CHELSEA
DORCHESTER
TEMPLE ISRAEL
Total Doses
In total, BIDMC’s site administered 93,707 doses of COVID-19 Vaccine. This accounts for 28% of all doses
administered through BILH. BILH administered 338,457 doses.
We collected data on patient experience throughout the clinics being open which helped us to gain
some good insight into what could have improved the experience for patients.
Vaccine Site
Chelsea
Chelsea
Dorchester
Dorchester
Chelsea
Patient Response to what could have been better
This was so easy, clean, and well organized. So much better than I
expected.
Your Chelsea Team deserves a patient care award.
Could not have been any easier or better than what I experienced
to today all was 100%
3-Mar-21
3-Mar-21
2-Mar-21
Someone playing the piano in the fellowship room would be lovely 3-Mar-21
The directions to the location should of been more clear because
the whole plaza is 1100 revere Beach parkway in Chelsea and it
For
more
brings you to a buffet when put
in the
gps information, contact:
2-Mar-21
Katelyn Rick, MSN, RN Manager, Improvement and Innovation krick@bidmc.Harvard.edu
�“I Got the Shot: The Story of COVID Vaccine Clinics in the Community"
Ellen Volpe, Kristin O’Reilly, Katelyn Rick, Jordan Ellis, Jaime Levash, Jasmine Cline-Bailey
BIDMC
More Results/Progress to Date
The Team
Ellen Volpe, Vice President - Ambulatory Services
Mary LaSalvia, Associate CMO, Infectious Diseases MD
Peggy Stephen, Chief Pharmacy Officer
Jarrod Dore, Director of Capital Facilities
Mo Ortega, Project Manager, Emergency Management
Sherry Calderon, Director, Ambulatory Services
Shari Gold-Gomez, Director, Interpreter Services
John Casavant, Manager, Telecommunications
Katelyn Rick, Project Manager for Chelsea
Kristin O’Reilly, Director Improvement and Innovation
Bridgid Joseph, Program Director ECC & Training Center Coordinator
Barbra Blair, Infectious Disease MD, Medical Director of Vaccines
Kyle Franko, Internal Communications Manager
Elise Porter, Site Director for Chelsea
Kerry Falvey, Site Director for Dorchester
Sandi Leitao, Site Director for Temple Israel
Larry Markson, Vice President of Information Systems
Divya Narayan, Project Manager IS
Jordan Ellis, Project Manager for Temple Israel
Jaime Levash, Project Manager for Dorchester
Jasmine Cline-Bailey, Project Manager
Sarah Moravick, Vice President- Organizational Planning
Julie Lanza, Pharmacy Compliance Specialist
Katie Scalzulli, Project Manager, Vaccine Staffing
Kerry Carnavale, CNS Nursing Educations for Vaccine Clinics
Kate Willetts, Nursing Educator
Paula Sterling, APP for Vaccine
Lessons Learned
The team learned to be flexible and pivot quickly when vaccine supply changed or was reallocated.
Leveraging relationships the clinics (Bowdoin, Chelsea internal medicine) have with their patients
proved to be an effective strategy to broaden our outreach and work through vaccine hesitancy.
We worked with IT to include patient language data and message a second time to all patients in their
primary language.
The BIDMC team created a “playbook” for how to open a vaccine site that was given to the BILH
system for the future.
Next Steps
The team is working towards rolling out a booster clinic for 3rd dose Moderna and 2nd dose J&J
For more information, contact:
Katelyn Rick, MSN, RN Manager, Improvement and Innovation krick@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
If you would like more information about this project, contact this person. Make email address clickable.
Katelyn Rick (<a href="mailto:krick@bidmc.harvard.edu" target="_blank" rel="noreferrer noopener">krick@bidmc.harvard.edu</a>)
Project Team
Ellen Volpe
Mary LaSalvia
Peggy Stephen
Jarrod Dore
Mo Ortega
Sherry Calderon
Shari Gold-Gomez
John Casavant
Katelyn Rick
Kristin O’Reilly
Bridgid Joseph
Barbra Blair
Kyle Franko
Elise Porter
Kerry Falvey
Sandi Leitao
Larry Markson
Divya Narayan
Jordan Ellis
Jaime Levash
Jasmine Cline-Bailey
Sarah Moravick
Julie Lanza
Katie Scalzulli
Kerry Carnavale
Kate Willetts
Paula Sterling
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
BID Healthcare - Chelsea
Community Health Center
Department
Any departments listed on the poster or identified in the spreadsheet.
Improvement and Innovation
Infectious Diseases
Ambulatory Services
Pharmacy
Information Systems
Organizational Planning
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
"I Got the Shot": The Story of COVID Vaccine Clinics in the Community
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
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/be1f907a04c91c807fc1ce39f85eef92.pdf?Expires=1712793600&Signature=Be2PZ1s0osXruxhnEenGxDoKIsqbT32MMffl3mpWf6To2cshxEiYdf44J%7E591O%7E%7ERq8jScq3Pb2X7m0SZRECpJWQARuKhr0YEN-CHKsxeflAhisA2zcErjZSXNwNQrXClK7477f5eFoEKItzTOHwzCdAy9gKtoFQ-p%7EpzbLx1KBWIvEhAnocsmDy3WbB6X-0hm5uloMUVWJBfcb7KIrdPc1TFFyYshMCNvpzXOPuia14%7EQW6PRHwKbJ7NVLyvDJ7r9hWvuXH6ueoenQLeorziZSzQL4xce5%7ExsCL1odICmY0L3bpT34maXlS8B6SaIhDLpJr97Xn%7EfaoE%7EUTosVbcg__&Key-Pair-Id=K6UGZS9ZTDSZM
794912fc492e34746e80144908a715f2
PDF Text
Text
Facing the Unknown with Data:
Strategies to Maximize Care Capacity for Resurgence of COVID-19
Aya Sato-DiLorenzo, RN, BSN, OCN, BMTCN; Jo Underhill, RN, BSN, OCN; Christine Flanagan, RN, MSN;
Matthew Weinstock, MD; Mary Linton Peters, MD; and Meghan Shea, MD
Ambulatory Hematology & Medical Oncology
Introduction
Hematology/Oncology Respiratory
Evaluation Emergency Extension Site
(Hem/Onc REEES) was established
in March 2020 with the following
goals:
•
To care for hematology and
oncology patients with respiratory
or other symptoms associated
with COVID-19.
•
To minimize delay in oncology
care delivery due to COVID-19.
•
To minimize unnecessary patient
visits to the emergency
department.
Problem
As we prepared for the winter of 20202021, the prevalence of COVID-19 was
expected to increase. With expected
patient influx at Hem/Onc REEES, there
was an urgent need to understand our
practice patterns and identify
improvement strategies to maximize our
care capacity.
Methodology
April 2020 Data
This project was conducted in the fall of 2020. We reviewed the unit log
from April 2020. It represented a period of high clinical acuity along with
the first wave of COVID-19 in our state.
Nursing interventions were identified by reviewing the billing data.
Furthermore, we analyzed appointment scheduling and duration on
selected days.
Based on the April 2020 data, we implemented Interventions likely to
promote high-quality, efficient care.
Structure
• Revised orientation plans
for deployed nurses with
focus on commonly given
interventions
• Planned to book 2-3
hours for patients
requiring urgent symptom
evaluations
• Lead-RN to oversee daily
unit operation and patient
flow
• A weekly “chemotherapy
day” with chemotherapy
competent nurses on site
• Weekly huddle between
clinic nurses and
leadership
Based on the Donabedian Framework
Results – January 2021
Total Clinic Encounters = 114
Average Visit Duration = 2hrs 32 min
Common Nursing Interventions:
• Nasopharyngeal specimen collection (n=100)
• Lab evaluation (n=52)
• Intravenous fluid administration (n=16)
• Blood products administration (n=2)
Many visits were added on the same day for
urgent patient evaluation.
Process
• Nursing processes as
per hospital policy
• Fidelity to REEES unit
SOPs
• Communication and
teamwork
Outcome
•
•
•
•
Maximize care capacity
Minimize care delay
Evidence-based care
Minimize nursing
burnout
Total Clinic Encounters = 95
Nursing Interventions Provided:
• Nasopharyngeal specimen collection
(n=76)*
• Lab evaluation (n=63)
• Chemotherapy/immunotherapy
administration (n=16)
• Intravenous fluid administration
(n=10)
• Injections including Leuprolide
Acetate, Octreotide, Cyanocobalamin,
& Pegfilgrastim (n=9)
• Blood products administration (n=9)
• tPA instillation (n=3)
• Non-chemotherapy IV therapeutics
including Belatacept, Ferumoxytol, &
Eculizumab (n=3)
• PK/PD draw for clinical trial (n=1)
* Decrease in the specimen collection at
Hem/Onc REEES was a result of more
patients using BIDMC drive thru testing
sites.
Winter 2020-2021: Unanticipated Challenges
Many other departments continued to operate for patient care.
• A smaller space available for the Hem/Onc REEES clinic.
• A fewer number of nursing staff who were deployed from other departments.
• No dedicated nursing assistants or administrative support on site.
• Patients with complex medical histories including those who had stem cell
transplant & chimeric antigen receptor T-cell therapy and those on clinical trials.
Conclusion
We were successful at expanding the
scope of Hem/Onc REEES. The clinic
utilization data showed the provision of
more complex, oncology-specific care
in January 2021 despite the smaller
physical space and a smaller number of
nursing staff.
�
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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
Project Team
Aya Sato-DiLorenzo
Jo Underhill
Christine Flanagan
Matthew Weinstock
Mary Linton Peters
Meghan Shea
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Primary Contact
If you would like more information about this project, contact this person. Make email address clickable.
Aya Sato-DiLorenzo <a href="mailto:%20">asato@bidmc.harvard.edu</a>
Department
Any departments listed on the poster or identified in the spreadsheet.
Ambulatory Hematology
Medical Oncology
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Date
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2021
Format
The file format, physical medium, or dimensions of the resource
pdf
Title
A name given to the resource
Facing the Unknown with Data: Strategies to Maximize Care Capacity for Resurgence of COVID-19
Effectiveness
Efficiency
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/bb47978d029e8ce272c5839b360ec759.pdf?Expires=1712793600&Signature=aUem1dQwzuTkgp3bS7eZPfdFrB82WemY2bn8DYJ0JDTmrNwD4BeiQQ%7Eh8ddl2z%7EiXJKCYP5xBXRKs%7E6rF7FABV8PtfiSJ1G0S0Qw2g%7E7eg%7ExA49RPBcMbAi3F8mGc-Wirl1BYN-pwoBKwmj6IUX-AvOaaoqDznMAr5xioSA-UBR1z4opBSCVSM7jkYglddjshUeCYO0cG%7E9CnP0dIVBsbigXi3uXVUUsA59FmCx2T8RtnjtEagwMDfs0a5dKNqq0KwmyeCcF%7EO2RN1wf1nvcsoroYjFo7orV2IyRQfiZEtVA922Pw0xbXTUhTH3l6sdcZ5SjC27U27oiKMwPt6jQbA__&Key-Pair-Id=K6UGZS9ZTDSZM
ed73b3c2a0bd82c41897ed01744307e5
PDF Text
Text
The Implementation of the Graduate Nurse Role to Support Nursing Staff during the COVID-19 Pandemic
Cassandra Plamondon, MSN, RN., Kym Peterson, MSN, RN, CNL., Kathy M. Baker, MSN, RN., Jenny Barsamian, DNP, RN., Ann Marie Grillo
Darcy, MSN, RN, ACNS-BC., Lynn Mackinson, MS, RN, ACNS-BS., Andrea Milano, MSN, RN, CCRN, CMC., & Lauren B. Mills, BSN, RN
Introduction/Problem
• Recognized critical staffing needs during the COVID-19 pandemic
• Governor Baker passed an executive order authorizing nursing graduates and senior nursing students
to practice with a limited capacity
• Current process did not support the role of the graduate nurse (GN) practicing in the clinical setting
Aim/Goal
• Increase the nursing workforce by implementing the GN role
• Swiftly create an orientation program that supported the GN amid the COVID-19 pandemic
The Team
Unit-Based Educators, Nurse Specialists, and Nursing Directors from inpatient medical-surgical and
specialty care units
The Interventions
Three phased approach tailored to the individual GN:
Phase 1
Phase 2
Phase 3
• Safety, basic assessments, documentation, prevention of harm, and use of basic equipment
• Advanced assessment skills, medication administration, emergency care, telemetry, and ECG monitoring
• Occurred once GN passed the NCLEX-RN exam and transitioned to the entry-level clinical nurse role
• Continued focus on medication safety, in addition to prioritization of care and evaluation of critical thinking
GNs were surveyed upon completion of orientation and their transition to the entry-level RN role to
assess comfort levels with various professional nursing roles and to identify knowledge gaps and areas
for improvement
The Outcomes
Fifteen of the 16 GNs successfully passed the NCLEX-RN and transitioned to an entry-level RN position with
12 responding to the survey. Six categories for discussion emerged:
Work experience
Communication and
feedback
Support
Clinical confidence
Workload
Transition challenges
• Ten had previous experience as a PCT, eight transitioned to a GN on the unit previously employed as a PCT
• GNs felt comfortable communicating with coworkers, physicians, and patients and their families
• Some reported a lack of communication regarding roles and responsibilities of the GN to other staff
• GNs reported seeking feedback for their performance
• Most felt supported on their units and felt the orientation process was well communicated with them
• Some stated that having several preceptors impacted the progression of their orientation
• Several GNs expressed lack of confidence in performing end of life care
• All felt they had adequate knowledge and experience to perform their job responsibilities
• Most felt comfortable with new situations and procedures
• Most GNs felt the workload was reasonable, feeling they could prioritize and organize patient care in a
timely manner and felt comfortable delegating tasks when necessary
• A lack of confidence and fear were challenges GNs identified during their transition to practice, followed by
perceived workload, role expectations, and how to use available resources
• GNs desired more experience with medication administration, eMAR, medical equipment, emergency
situations, and how to communicate efficiently with physicians
Implications for Future
• Improve communication with nursing staff to
increase the understanding of the roles,
responsibilities, and limitations of those in the
GN role
• Limit number of preceptors orienting a GN to
one or two key preceptors and ensure
communication occurs amongst those sharing
this role
For more information, contact:
Cassandra Plamondon, MSN, RN – cplamond@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
If you would like more information about this project, contact this person. Make email address clickable.
Cassandra Plamondon (<a href="mailto:cplamond@bidmc.harvard.edu" target="_blank" rel="noreferrer noopener">cplamond@bidmc.harvard.edu</a>)
Project Team
Cassandra Plamondon
Kym Peterson
Kathy M. Baker
Jenny Barsamian
Ann Marie Grillo Darcy
Lynn Mackinson
Andrea Milano
Lauren B. Mills
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.
Nursing
Dublin Core
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Title
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The Implementation of the Graduate Nurse Role to Support Nursing Staff During the COVID-19 Pandemic
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
Safety
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/055f07d74179b83ef0282d00dad2ad2f.pdf?Expires=1712793600&Signature=e-bWGwcI-RazVxL0s1RWVrPt2DMEy9OZajf9mEhso3y9T3r0P1I2Kov0yNCHbSnSXjZJS2E6BS3HwbM78RGVcSoZab%7EMuilG5R5zXt5HXgnk4baaeoX6izM-dPBWR1rtvDCC25o26pgPf9-8UnkoYu2bA2UimvugSKXmL9y8TfYbnB1jEGZMbgqFKNeb33SVvZIhsAj%7EcU-p9Y7bygyluE2tmj9nMIoTQk5UUzTzc2Zx0Es0ZPQ1PTix5rnwFEjIFgoDOY2sNQg4ep%7EIq5JZDFSi1b5lfObg7hbhdWm9vpHRiPUFOyiDnQ2pYxqdYnN8Ok6H-yUnxBCOsO0dXZiUrw__&Key-Pair-Id=K6UGZS9ZTDSZM
ee276e8f612864b4542a40aceed958bd
PDF Text
Text
JUST-IN-TIME IN-SITU SIMULATION REFRESHER TRAINING FOR THE PERIOPERATIVE CARE OF COVID-19 PATIENTS
SS Obeidat1, MJ Needham1, Jeffrey Keane1, Michael Chen1, L Zucco2, N Levy1, John Mitchell1, & SK Ramachandran1
1Beth Israel Deaconess Medical Center & 2Guy’s and St. Thomas’ NHS Foundation Trust
Introduction/Problem
Results
In-person
Virtual
Grand Total
Our just-in-time in-situ simulation training program, initially developed and implemented during the first
surge in March 2020, was reformatted in order to deliver refresher training to perioperative staff
members, from anesthesia, nursing and surgery staff members.
Anesthesia
199
73
272
In order to keep our practice of safe COVID-19 patients care in the perioperative setting and in
anticipation of the second surge of COVID-19, we provided in-situ training to “refresh” staff members on
the hospital updated specific workflow.
Surgery
12
4
16
Nursing
129
29
158
Grand Total
340
106
446
Feedback
Aim/Goal
The goal of the training was to assure staff readiness to safely provide care for COVID-19 patients,
minimize viral exposure and reduce the risk of transmission of COVID-19 to healthcare workers in the
perioperative setting.
Feedback reflected an appreciation for the brevity, the ability to complete training using the
preferred modality of the participant and the timeliness.
Feedback from staff members who were involved in the perioperative care of COVID-19 patients,
confirmed that appropriate protocols were followed in nearly 90% of all COVID-19 cases.
The Interventions
Refresher training was delivered over the course of 5 days in late November 2020, it was available to
each hospital site within the BI network. Attendance at each station/simulation scenario was tracked
using a QR code, which also contained a post-training question to assess knowledge of key concepts
within each station.
Given routine operating continued during the second wave, (staff members not readily available and
operating rooms would be occupied), we reformatted our COVID-19 training program to include
several modalities; online learning using a video recording, in-person training using drop-in stations
and didactic sessions through joint town hall meetings and grand round presentations.
Training Focused on donning & doffing of personal protective equipment (PPE), performing a COVID19 specific pre-operative huddle, and the use of appropriate infection control measures when
intubating or extubating.
For more information contact:
anesthesiaqsifellows@bidmc.Harvard.edu
For more information, contact:
�
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.
SS Obeidat <a href="mailto:%20">sobeidat@bidmc.harvard.edu</a>
Project Team
SS Obeidat
MJ Needham
Jeffrey Keane
Michael Chen
L Zucco
N Levy
John Mitchell
SK Ramachandran
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.
Anesthesia
Nursing
Surgery
Anesthesia
Nursing
Surgery
Dublin Core
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Title
A name given to the resource
Just-in-time In-Situ Simulation Refresher Training for the Perioperative Care of COVID-19 Patients
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
Safety
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/01403eec0838fe9903bc585d2a4c7396.pdf?Expires=1712793600&Signature=LLSfmX4VPISy4PD7iZ7NNpiS8TR2BelMom3EVeUgNCWaQh-UHocOC9dAighq%7Ep7mS4iMp-hPJGEJG%7EIm3xKi1fgO5SgE%7EgZxfoM46Ya9O6XWNnAT3DBmIhoknYXFNE8ZQLxgzYtd6flGzQL%7EIPMYIMduzMnKi2z68m0a5m47U-Voc%7EudC7do1szDJaemWkpTjilALO8Tw78UqS61%7E0mLiFKWmWbG0ATpqLfj1XpOFy3bU1CDGHa0FZXugqgofyojamO3MFlM4qBLEzyGV3H1i7%7E0PPUxMgt1sGIa8Jo7TgiTfQKtNys4488B%7Efl5x7zeKhGwmo9PGQ3zE1zOkLO5hw__&Key-Pair-Id=K6UGZS9ZTDSZM
3162c576e41aefead167bc2f78bf9a19
PDF Text
Text
Hematology/Oncology Admissions
Tara Meekins RN and Tonia Valeri RN
Ambulatory Units: Shapiro 7, Gryzmish 7
Introduction
Our project is geared towards
Hematology/Oncology clinic
patients who have scheduled
clinic visits with same day
admission for chemotherapy. Our
clinic volume has increased with
higher levels of acuity as well as
the added burden of social
distancing during the Covid
pandemic which has made it
difficult to accommodate patients
waiting in clinic purely for an
available admission bed which
can take many hours. In order to
provide treatment for our
scheduled treatment patients
safely and without excessive
delay, we needed to alter our
planned admission process.
Method
The change of practice adopted is to schedule the patients
for planned chemotherapy admissions to clinic 24 hours
before their planned admission. The clinic visit entails a
pre-admission Covid swab, labs, any schedules test (i.e.
EKG/PFT/CXR) and physician exam that will authorize next
day admission. This also allows for high cost drugs (ie
Rituxan) to be administered on the day prior to admission.
t
Conclusion
Changing our planned admission
method to having our patients come to
clinic 24 hours in advance to their
planned admission (as opposed to
same day) has increased patient and
health care team satisfaction.
This has resulted in a quicker clinic
visit for the patient and allowed the
patient to wait in the comfort of their
home the next day to await for a
hospital bed for their planned in-patient
chemotherapy regimen.
This increases patient safety as it
allows time for a Covid swab to result
and helps support social distancing by
reducing crowding in the clinic.
This has also helped healthcare
team members, giving adequate time
to analyze lab results and organize
appropriate oncology intervention with
appropriate bed placement (ie shared
or private room).
�Hematology/Oncology Admissions
Tara Meekins RN and Tonia Valeri RN
Proposal for Planned
Admissions
1. Moving forward, all planned
admissions will have Clinic visit
(MD/NP appointment) with labs
and Covid swab done the day prior
to planned admission. Along with
labs and covid swab, the
practitioner will verify with 7F or
11R that the planned admission is
in the book and that the patient is
cleared to be called from home the
following day to come in when bed
is ready. MD will place and sign
future Chemotherapy order.
Day -1
2. Patients will be called at home by
the admitting floor the following day
when room is available to come
into the hospital for planned
admission.
Day 0
Ambulatory Units: Shapiro 7, Gryzmish 7
Advantages of next day Planned Admits
Increased patient satisfaction, allowing them to wait comfortably at home for
an available bed as opposed to in a busy clinic lobby for prolonged time.
This will also help increase safety, ensuring a covid swab is done with a
reliable result time for that covid swab before admission.
Next day admission allowed a quicker clinic visit which reduced waiting for a
bed in a crowded lobby.
Allows clinician to verify that patient is in the book for planned admission to
ensure a bed will be available the next day.
Limited bed holds for patients that may not be eligible for the planned admit
due to abnormal lab results. This results in better utilization of limited
in-patient beds.
Fiscally, this allows providers to charge for a clinic visit as it won’t be on
same day as admission.
This also allows us to charge for any RN intervention or treatments such as
administration of Rituxan as it is separate from admission day. We can’t
credit a charge on the same day as admission from the clinic.
Resource Nurse can now focus on supporting nursing care to the scheduled
patient treatments in the clinic and focus on unplanned admissions as
opposed to acting as a liaison to the same day admission process (checking
bed status and providing updates and then transportation for patient to get
to floor).
Advantages of next day
Planned Admits
This allows physicians time to fully
review lab results along with
patient evaluation to determine
safety of planned admission for
chemotherapy.
This also allows time to write the
chemotherapy regimen in advance
(Day -1), ensuring it is signed and
ready to be verified on admission
(Day 0).
This gives time for all the
healthcare team members to
prepare for the admission,
including nursing and pharmacy.
Ultimately this reduces delays,
increases safety and satisfaction
for the patient being admitted.
�Hematology/Oncology Admissions
Tara Meekins RN and Tonia Valeri RN
Ambulatory Units: Shapiro 7, Gryzmish 7
Nursing Professional
Governance
Allowing nurses the time to evaluate
practice and work environment to find
areas of improvement and
empowering them to help implement
changes to these areas help improve
patient satisfaction and outcomes
along with increased workplace
satisfaction.
Disadvantages of Same Day Admissions
● Patients voice frustration and dissatisfaction with the long wait time before
their bed is available for them. They voice feeling “forgotten about” when
they are left in an exam room or in a busy lobby.
● As the clinic volume has increased with higher levels of acuity, it is
becoming very difficult to accommodate patients waiting in clinic purely for
an available admission bed. We have limited spaces to provide scheduled
treatments and have increasingly had a waiting list for patients to come
back to treatment area due to no beds or chairs available. This results in a
very full lobby and delays in care.
● It becomes harder to provide safe environment with social distancing with
clinic volume increasing.
● It is and will continue to be important to have a covid swab result to
determine treatment and bed placement, there are times when same day
admissions have not had their covid swab done or resulted in time.
● There are instances when planned admissions were not communicated
correctly and the floor has no bed reserved, resulting in a scramble to find a
bed, sometimes after 6pm which delays onset of planned treatment to the
next day.
● Treatments or interventions done in clinic can not be billed if patient is
admitted on same day. Hospital does not get reimbursed for high cost drugs
like Rituxan administered in clinic if patient is admitted the same day.
Changing Disadvantages to
Advantages
Shapiro 7 - Gryzmish 7 - Feldberg 7
This change was initiated by the
nurses in the ambulatory setting to
help with our admission process.
Oncology is increasingly moving to
the outpatient setting which has
resulted in large clinic patient
volumes. This is a challenge to our
limited physical space and limited
time in the clinic day. The Covid
pandemic has added to this, having
to ensure proper patient symptom
screening and maintaining social
distancing.
Our planned admission process
was one area we focused on to help
reduce crowding in the clinic. We
worked in collaboration with the
physicians, admitting floors and
pharmacy to ensure the proposed
changes were safely implemented.
�
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.
Tara Meekins (<a href="mailto:tmeekins@harvard.bidmc.edu" target="_blank" rel="noreferrer noopener">tmeekins@harvard.bidmc.edu</a>)
Project Team
Tara Meekins
Tonia Valeri
Brendan Sendrowski
Caroline Meijas
Sarah Marcinowicsz
Jo Underhill
Matthew Weinstock
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.
Hematology and Oncology
Ambulatory Units Shapiro 7
Ambulatory Units Gryzmish 7
Pharmacy
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
Hematology/Oncology Admissions
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
Efficiency
Safety
Timeliness
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/151880e0917fd1e491b7aab5c7917f54.pdf?Expires=1712793600&Signature=WKZtUGZ7wU4qUpq4pJPO3pm6HQHpitUwOj8DdzYJR3EUu0pTBxME2jIw7flMyg4CoI9GRUfvXZPQRBxRVhBGJMmnl56bn9IP5LtOHcmjhnkTLk9Nj7lOtJOH4gIVvNXSVoXjLv88XlJyWl-DfjPGMsKaFFlHVRQ-tgQ5WkWhNCvWjXaklhhD-4eGKpFXuC0wHazX9glJqw0KsFsRalZQ5iwxtC%7EoYnkiDNSA4gwhohldPujCju1Y8eHGOX%7ENjcRVn9EZZvTb5OklxcW0i2DsLEQf%7EJ1QYMJSnL%7E3cg7JQFmEAUW9gMh-0ACbCzYFXC4TxStJRH6KFQmsFw-4SlrYBg__&Key-Pair-Id=K6UGZS9ZTDSZM
3b1d4200ecd2a6b5ddd6f0b3c05425fc
PDF Text
Text
Social Work Response to COVID
Mary McDonough, LICSW
Social Work Department, Clinical Manager of Med/Surg, ED and Transplant
Beth Israel Deaconess Medical Center
Introduction/Problem
How did inpatient social work team respond to needs presented by pandemic beginning March 2020
Initial concerns regarding safety, ability to meet needs of patients, families and staff.
The Interventions
Staffing
Work on units
Support to pts and families
Staff support
A whole new focus in our work in collaborating with teams to facilitate end of life visitation, working with
on line meetings, discussions of end of life decision making via ipads.
Readjusting to new world of resource needs, transportation, shelter limits, dialysis unit limitation, court
closures.
Providing support to staff, informal and formal support modalities, in person vs remote,
groups/individuals, bringing in resources.
Aim/Goal
Results/Progress to Date
Immediate response
What worked
Pulling team together immediately, 3/13 met w/ whole team in person, didn’t have
tools yet for zoom, etc.
Decision made to work 50/50 onsite/remote
To respond to needs of patients, families, and staff during differing stages of COVID pandemic
To adjust staffing to meet needs of patients, families, and staff.
The Team
Medical Surgical Social Work Team
Safety concerns
Remote vs onsite work
Working in teams to provide response to inpatient units
Requirement daily “pod” check ins to make sure that patient needs addressed
What didn’t work
Unclear message to patient care units,
Interpreted as we “went home” altho more than half the staff and both leaders were
here on site 100%
Eventually developed on site requirement, but created more flexible schedules with 10 hour days to allow for some
social distancing and address staff exhaustion. Still evaluating effectiveness
Collaboration throughout the medical center, often standing with spiritual care colleagues.
For more information, contact:
�Social Work Response to COVID
Mary McDonough, LICSW
Social Work Department, Clinical Manager of Med/Surg, ED and Transplant
Beth Israel Deaconess Medical Center
More Results/Progress to Date
STAFF SUPPORT
WORK ON UNITS
Quickly became almost all COVID patients
ICU’s expanded beds to RB6, RB7
Primary role in end of life care
Strengths:
Formal and informal leadership within social work group
MICU/SICU Social Worker and RB 7 Social Worker became
interchangeable
Challenges:
Some staff unprepared for end of life work
Staff were not sufficiently cross trained to work in other units
Responding to the needs of the responders
Formal and informal support
Inpatient support groups, led by social workers (inpatient and outpatient) and chaplaincy
Inconsistent participation but some very powerful moments and times on patient care units
Mostly effective with/from social workers well known to units
Outpatient staff want to be helpful but hard to do by Zoom and hard to predict time that worked
Informal support most often what worked, staying late after a hard shift, debriefs after a hard death
Lots of tears, few hugs
Lessons Learned
SUPPORT TO PATIENTS AND FAMILIES
Became proficient in zoom, facetime, and other technologies
Coordinated arrival of IPADS on patient care units
Coordinated end of life visitation in collaboration with medical, nursing leadership, hospitality staff, public safety, and Spiritual Care
Prepared families for visits, escorted families from lobbies
Strengths:
Great collaboration to meet needs of families, everyone just picked up
whatever they needed to get it done
Challenges:
Guidelines kept changing, weekly meetings addressed outpatient and clinic
visits, cafeteria visits but not very clear about managing inpatient visits
Weekend staffing, late evening staffing
Social Work drop in time
Working in crisis mode, not best decision making
Changing guidelines really hard to keep up with
More cross training needed, internal shadowing
Need to evaluate effectiveness of changed schedules
Turn over of staff, pulled manager away from staff to cover for almost a year,
Next Steps
Reevaluate pros and cons of 4 day work weeks
Survivor mentality, grown in closeness, 9 new hires since beginning of pandemic, 30% turnover of
staff, redeveloping identity of group
For more information, contact:
�
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.
Mary McDonough (<a href="mailto:mmcdonou@bidmc.harvard.edu" target="_blank" rel="noreferrer noopener">mmcdonou@bidmc.harvard.edu</a>)
Project Team
Medical-Surgical Social Work Team
Department
Any departments listed on the poster or identified in the spreadsheet.
Social Work
Spirtual Care
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
Social Work Response to 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
Effectiveness
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/be26ada387978e266df6fd27aa9f4f25.pdf?Expires=1712793600&Signature=e3aY7zI9-LWGsS7vvlDIw9kK5mG-JmyH-QRi1g%7EE3866nupOUThUCS5qq2PcTN36ZwgmAZVBqutKJe%7ELMDBWL3YmDNWwceWvysWKKWSYUfZoT7tL1nDTfUpUpUfpAbGYDWCYclYPKZdkYgjq1iLx3Qo6uyenrtsDqGTJ547pZuur0UNsu7YMCaqsjxNjmzKALY93I3GAinxhvdoOtfbvR6akcsLS8j5K1k5WwzpqeZ53wWt3V9YQZYnTI2iR3oP%7E6lrLeFgDfN8ovu2djp3T6ujihy50sJEvEb3JXec5Rw2OEOKw0HsduWC2J4mEu6rVSEr7mj%7EC51DCI6YRB4IUtQ__&Key-Pair-Id=K6UGZS9ZTDSZM
3c6f5f0f9aaef4f2c74ff5f8136acce3
PDF Text
Text
Rolling Out Remdesivir Under EUA
By Julius Yang, MD and Jaime Levash
Beth Israel Deaconess Medical Center
Introduction/Problem
Results/Progress to Date
May 1, 2020 the Food and Drug Administration (FDA) issued an Emergency Use Authorization (EUA) for
the emergency use of remdesivir for the treatment of hospitalized patients with severe COVID-19. EUAs
are a relatively new pathway that the FDA can utilize when there is a declared health emergency. During
the health emergency, things were moving quickly.
Aim/Goal
The goal was to understand the EUA and roll out the medication across the medical center as quickly as
possible to help save patients’ lives.
May Adra, PharmD
Michael Cocchi, MD
Mary Ifeoma Eche, PharmD
David Feinbloom, MD
Kyle Franko
Howard Gold, MD
Margaret Hayes, MD
John Hrenko, RPh
Mary LaSaliva, MD
The Team
Jaime Levash
Christopher McCoy, PharmD
Ari Moskowitz, MD
Ameeka Pannu, MD
Todd Sarge, MD
Roger Shapiro, MD
Lauge Sokol-Hessner, MD
David Sontag
Conor Stack, MD
Margaret Stephan, RPh
Kathryn Stephenson, MD
Kim Sulmonte, DNP
Daniel Taupin, MD
Cheryle Totte, RN
Julius Yang, MD
The Interventions
Created three working groups:
– An Oversight Committee has met to oversee guideline implementation, monitor drug supply, ensure
effective communication with staff and patients, and ensure adherence to ethical, regulatory, and
patient-centered best practice.
– A small Interdisciplinary Advisory Workgroup was developed a consensus allocation prioritization
guideline based on available evidence and experience regarding treatment of COVID-19 with
remdesivir.
– A Clinical Review Team met daily to review patients potentially eligible for remdesivir EUA allocation
per BIDMC guideline, and authorize release from Pharmacy for individual patients.
83% of patients treated with Remdesivir were
discharged home or still in the hospital. Only
17% of patients who agreed to treatment
expired.
Lessons Learned
Create a multidisciplinary team.
Clear communication to providers explaining the steps to communicate with their patient, order the
medication, and documentation needed.
Administration of remdesivir earlier in illness is more beneficial then later in illness.
Next Steps
The 3 workgroups dismantled. Remdesivir was approved by the FDA in early October 2020 which means no
longer a need to complete additional tracking on the amount of medication dispensed, no formal reaction
tracking to the FDA, and no prioritization amongst patients since supply was abundant.
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 (j<a href="mailto:jlevash@bidmc.harvard.edu" target="_blank" rel="noreferrer noopener">levash@bidmc.harvard.edu</a>)
Project Team
May Adra
Michael Cocchi
Mary Ifeoma Eche
David Feinbloom
Kyle Franko
Howard Gold
Margaret Hayes
John Hrenko
Mary LaSaliva
Jaime Levash
Christopher McCoy
Ari Moskowitz
Ameeka Pannu
Todd Sarge
Roger Shapiro
Lauge Sokol-Hessner
David Sontag
Conor Stack
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.
Pharmacy
Marketing and Communications
Infectious Disease
Healthcare Quality and Patient Safety
Nursing
Emergency Medicine
Anesthesia
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/.
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
Title
A name given to the resource
Rolling Out Remdesivir Under EUA
Effectiveness
Safety
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/0fa49a0f310dd7b99d6ec818782fe93a.pdf?Expires=1712793600&Signature=WFTn7lLWnU6UulevzCkLwmCIq9tMDMecvaz1P2H1lCJnzi6EIm9LYEiayAsu1cC29cdg33a%7Ei6cJ-Oe%7EpFGIk0u14bOdGJMVchAqFq%7EaiH8ot-FPVKRh4f1lSPMyDsZeenE2LDW%7E3052mUOoSV%7EuhdXCEN0lWIWkU0NcIW1-mLr3%7ErZi-MNVl4uONEPxFXBUCNdiBxSmrGSoL60o-LqlhcPONABsqOoV29-qKJ-grYBdNI6Y1XmG1NZqeLGkrYBW9mNmCfYNSRoIJspWMNflu3dHfnEA9iqKwcu3CY4OX3yIDMQ3xE%7EtpaYejagoHewULzxUrBkWBftlU0YRJhS4Cg__&Key-Pair-Id=K6UGZS9ZTDSZM
28590d37b3dc0491bd013e2039a85384
PDF Text
Text
COVID-19 Monoclonal Antibody Therapy Implementation
By Mary LaSalvia, MD, Jaime Levash, Paula Stering, PA-C and Daniel Taupin, MD
Beth Israel Deaconess Medical Center
On November 13, 2020 the Massachusetts Department of Public Health (DPH) released a questionnaire to
determine which facilities had the capacity to treat COVID-19 positive patients in an outpatient setting.
BIDMC began preparing for an anticipated allocation of bamlivinimab (BAM) treatment. However, it was
decided implementing this treatment at BIDMC would not be feasible with uncertain drug allocation and the
challenge of bringing in COVID-19 positive patients into an ambulatory site. At the end of April, the group
moved forward with launching our ambulatory monoclonal Ab therapy clinic starting with casirivimab &
imdevimab which is under Emergency Use Authorization (EUA) by Food and Drug Administration (FDA).
Aim/Goal
The goal was to understand the rapidly-changing EUA and secure access to clinical space and resources in
order provide treatment to patients with COVID-19 who are at high risk for complications.
The Team
Jared Dore
Holly Creveling, PharmD
Kyle Franko
Howard Gold, MD
Michelle Knox, RN
Nicolas Kriketos
Mary LaSaliva, MD
Jaime Levash
Christopher McCoy, PharmD
Debra Melia, RN
Sara Montanari
Theresa Normile, RN
Margaret Stephan, RPh
Paula Stering, PA-C
Daniel Taupin, MD
Ellen Volpe
Julius Yang, MD
The Interventions
Worked with facilities to determine clinic location and ordering of equipment and supplies
Outlined a process for how the clinic would flow: referrals, documentation, scheduling, directions, and
communication with teams surrounding clinic
Outlined safety protocols in case of infusion reaction
Recruited and trained staff
Created a dashboard for team to review patients
Work with the drug shortage task force to develop a prioritization scheme
Worked with Lahey to open a second clinic to serve BILH patients
# Patients Treated
Introduction/Problem
80
70
60
50
40
30
20
10
0
Results/Progress to Date
Number of patients treated
172 patients (as of 10/27/21)
July '21
Aug '21
Sept '21
Oct '21
Lessons Learned
The multidisciplinary team learned to be flexible and pivot quickly when changes occurred with the EUA
and DPH allocation processes.
The importance of clear communication to providers explaining the steps to communicate with their
patient, order the medication, and provide necessary documentation.
The benefit and challenges of working across the network to provide equitable access to high-risk patients
across the city and state
Next Steps
Continue to expand treatment options; specifically for post-exposure prophylaxis for patients with severe
immunosuppression.
Finalize a shared electronic tracking system between Lahey and BIDMC.
COVID-19 positive test results will include information on monoclonal antibody therapy
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 j<a href="mailto:%20">levash@bidmc.harvard.edu</a>
Project Team
Jared Dore
Holly Creveling
Kyle Franko
Howard Gold
Michelle Knox
Nicolas Kriketos
Mary LaSaliva
Jaime Levash
Christopher McCoy
Debra Melia
Sara Montanari
Theresa Normile
Margaret Stephan
Paula Stering
Daniel Taupin
Ellen Volpe
Julius Yang
Margaret Stephan
Kathryn Stephenson
Kim Sulmonte
Daniel Taupin
Cheryle Totte
Julius Yang
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
COVID-19 Monoclonal Antibody Therapy Implementation
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
Safety
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
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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.
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/6fb39b4bbfae13b2e30376d0129e9af5.pdf?Expires=1712793600&Signature=uDD1NNKMnCLIeNLF1PQfYfh5ylgzv80Je9-BmmQkiMGAU54FNCzpdaAbPT70rN2KaK9QtLQJFLoyEFI9DRZDsqTLs2Np2nbK6kAKSmfPtV-xNjQnBu1a90a9F80GffUVUQcjrpkbF2j1%7ECRdNDlrM6wjQAHj0og4sGWaLOQR7Up9UJExEyrr3zPUqvk9KYQ-%7EgpN8Q-SvyZzCwSYOlVE7dElELuQv435fHvIY48ktxzDvLWH4NJC%7ESPDrpzYaEBzdx7f4-8Jq2eGI9dotlgzbOcU2LaRSoc2LlqGx9rZ-64oAjqVpg8yDsaUStxuro%7E1cD6g%7EpGdAzphJLUm7Cxbwg__&Key-Pair-Id=K6UGZS9ZTDSZM
5427a0dda52e48e396dd92acb2d5e622
PDF Text
Text
Management of a COVID-19 patient in the endoscopy suite
Joseph D. Feuerstein, MD, Nadav Levy, MD,,∗ Liana Zucco, MBBS, MSc, Lior A. Levy, MD, Mandeep Sawhney, MD
and Satya Krishna Ramachandran, MD2 Presenter: Mitra Khany MD
Introduction
Since the COVID-19 pandemic started in December 2019, gastroenterologists
have had to rapidly evolve their endoscopy practice to ensure the safety of
endoscopy team members and their patients. Because the virus is transmitted via
droplets and potentially via airborne inhalation of aerosolized particles,
endoscopic procedures performed on patients with confirmed or suspected
COVID-19 increase the risk of transmission to healthcare providers. To minimize
the risk of exposure among healthcare workers and patients, protocols and
algorithms to reduce inadvertent transmission of the disease is critical. In this
article, we review the workflow that was developed by the coordinated efforts of
the Department of Anesthesia and the Division of Gastroenterology at Beth Israel
Deaconess Medical Center in Boston available.
GI procedural algorithm for COVID-19. PPE, Personal protective equipment; ICU, intensive care
unit; SOP, standard operating procedures.
Aim
To keep providers safe during endoscopic procedures during the COVID19 pandemic, it is critical that protocols are developed to maintain proper
PPE and limit the risk of exposures. Simulations and flow diagrams are
important tools to train staff on how to perform endoscopy safely.
For more information, contact:
�Management of a COVID-19 patient in the endoscopy suite
Pre-procedure Considerations
To reduce the risk and time of exposure of healthcare personnel to patients with COVID-19, consider
obtaining all procedure consent verbally.
all nonessential equipment should be removed from the room
Any equipment essential to the procedure or nonessential equipment that cannot be moved should be
covered in clear plastic drapes to minimize potential contamination of the equipment.
Once equipment is brought into the endoscopy room, it should be discarded, even if unopened.
Alternatively, equipment can be kept in a double bag; then, if the equipment is not used, one can discard the
outer bag only.
One should consider intubation for all endoscopic procedures (especially upper endoscopic procedures) to
reduce the risk of droplet exposure
A safety officer should be identified; the safety officer will be responsible for ensuring proper donning and
doffing of PPE and monitoring the outside door to the endoscopy room to make sure no one enters the
room without proper PPE.
Discussions during the huddle should include the following: which personnel will be in the room versus
outside the room, what procedure is planned and what equipment will be needed in the room or prepared
outside the room, patient disposition, and whether any additional resources are needed (eg, environment
services).
Donning PPE
Remove all nonessential/personal equipment.
Perform hand hygiene: wash your hands with soap and water or hospital-approved hand
sanitizer.
Apply head cover.
Apply N95 respirator and ensure adequate seal.
Apply eye protection (or a secondary facemask with eye shield over the N95 respirator).
Perform hand hygiene.
Apply shoe covers (option to apply leg covers, if available).
Don and secure impermeable gown.
Don 2 sets of gloves on each hand, ensuring wrists are cover
Confirm with safety officer that all PPE is donned correctly.
Patient arrival
COVID-19 patients should be brought directly into the procedure room while wearing a surgical facemask.
Shared spaces should be avoided
Procedure
1: A timeout should be performed, and all nonessential personnel should exit the room during intubation to
limit the number of people exposed during intubation
2: Once intubation is complete, the nurse in the room can open the door, allowing re-entrance to the
room
3:During the procedure using gauze to cover the instrument channel on removal may be helpful. Once the
procedure is nearing completion, the endoscopist should advise the team that the scope is being
withdrawn. Using gauze to cover the endoscope, suctioning secretions on withdrawal, and having the
nurse cover the mouth with gauze are all advisable
Doffing of PPE
Remove shoe covers (and/or leg covers if present).
Remove gown and gloves and then perform hand hygiene.
If wearing an eye shield, remove eye shield and perform hand hygiene.
Remove outer facemask and perform hand hygiene.
Remove N95 while leaning slightly forward, discard N95, and perform hand hygiene.
Remove bouffant and perform hand hygiene.
Apply a clean facemask and perform hand hygiene.
Ensure the safety officer is supervising the doffing sequence.
Post Procedural Consideration and Special Events
After the procedure, the room should be left closed for 30 minutes to reduce any exposure to
procedure-related droplets that might remain aerosolized. The room and endoscope can then be
disinfected using routine hospital/institutional protocols for cleaning rooms and endoscopes
In case of adverse event the provider’s safety is the priority. Making sure that responders to CODE call
For more information, contact:
do not enter the room if PPE is not appropriate.
�
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.
Mitra Khany <a href="mailto:%20">mkhany@bidmc.harvard.edu</a>
Project Team
Joseph D. Feuerstein
Nadav Levy
Liana Zucco
Lior A. Levy
Mandeep Sawhney
Satya Krishna Ramachandran
Mitra Khany
Department
Any departments listed on the poster or identified in the spreadsheet.
Anesthesia
Critical Care
Pain Medicine
Gastroenterology
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
Management of a COVID-19 Patient in the Endoscopy Suite
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
Safety
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/06af63b82e7567aea9f359021d47aee5.pdf?Expires=1712793600&Signature=v8IoMRwJP4lgBZdyWUSObVxAJ0EOzKvWE8CtZxGy4mHNgROHNNg1xXWb3DtOFkuDkhJpSMt5AF76geyPR-qVC3JN1sDC5ngygNLHwopdSjvrqzK6hVt2gsFXTqzvm7RpycOjvys9iz1y%7EcqLynBSTm1uj2Zt3%7EmQEiZUIloaY7WMaNPbYAs3byDRkMq1U8392ebeBjXf6tJOskk2AfZ5Fb41%7EjAUO%7ETUSqsJKXKRKeDzq7LGlMMKbPproq00FN5qIKjVY2mIaUC9HKAiZgA4ELl6fS74LoHixXtT6HijB76NTAA7f1GLo9yzA3nDqbel4G557m-m7NSSQuyrpFC5DQ__&Key-Pair-Id=K6UGZS9ZTDSZM
ed0bec646b7220e530ede69b6281d757
PDF Text
Text
Collaboration Between Departments to Identify a Gap in a High Risk, Low Volume Safety Process
Susan Holland, EdD, MSN, RN, NEA-BC, HealthCare Quality, Aya Sato-Dilorenzo, BSN, RN, OCN, BMTCN, Cancer Center Quality Improvement,
Christine Powers, MPH, MBA, Director of Environmental Health and Safety, and Deb Crowley, Telecommunications Manager
Problem
A Chemotherapy spill occurred in an Outpatient Treatment Area. The spill was determined to be larger
than could be contained as described in the BIDMC Policy, 1200-17, Nursing Practice During a
Hazardous Drug (including chemotherapy) Spill.
The nurse called, 2-1212 and informed the MASCO Operator that they were calling a Code Orange and
answered the questions asked by the Operator. Soon after, one of the Pharmacists came to the treatment
area with limited supplies for spill management as the East Campus Pharmacy was notified to respond to
the Code Orange.
The nurses were then told to call the Service Response Center (SRC) which they then did , and they
deployed Environmental Services/ housekeeping staff (EVS) to the treatment area. However, their
seemed to be a knowledge deficit of the EVS staff and cleaning chemo spills (for example those who
responded, did not know that they should wear gloves or a gown during the process). The nurses guided
the EVS staff so they were properly protected, and were instructed to assist EVS in the spill
management.
An RL Safety Report was entered regarding the Code Orange and as the event was reviewed, it was
discovered that the BIDMC Policy, EC-43, Hazardous Spill Response Program, (“CODE ORANGE) did
not match actual practice, and a larger investigation began.
Goal
To review the EC-43, Hazardous Spill Response Program, (“CODE ORANGE) policy and identify
breakdowns in communication so that the appropriate and most knowledgeable team members would be
notified when a “CODE ORANGE” was called.
The Team
Deb Crowley, Manager of Telecommunications
Susan Holland, EdD, MSN, RN, NEA-BC, Patient Safety Coordinator and Risk Manager
Christine Powers, MPH/ MBA, Director of Environmental Health and Safety
Aya Sato-Dilorenzo, BSN, RN, OCN, BMTCN, Cancer Center Quality Improvement
Members of: Emergency Management, Materials Logistics, Shapiro 9 Nursing Staff, Pharmacy,
Environmental Services and MASCO
Investigation
Discovered that instructions that MASCO was given did not match our current policy of EC-43,
Hazardous Spill Response Program, (“CODE ORANGE)
When a staff member dialed 2-1212 and reported a CODE ORANGE, the Operator was instructed to
ask if the Code Orange was related to a medication or blood/ body fluid:
If YES to a medication, then the East Campus Pharmacy would be notified to respond to that
location/ caller
If YES to blood or body fluid, then SRC/ EVS would be notified to respond to that location/
caller
AND if YES to either of these questions, the notification process would stop and the CODE
ORANGE page would never go out to Environmental Health and Safety (EHS) or others.
However, if NO to either of these questions, then the CODE ORANGE page would go out to
EHS and others
Interventions and Outcomes
Communication with MASCO to ensure they have the correct information: when a CODE
ORANGE is activated, a page is always sent to the pager distribution list including EHS
Environmental Health and Safety and Emergency Management now have automatic access to,
and receive notification of Facilities, Environment of Care, and Safety related RL Reports
Anticipate improved staff satisfaction with the level of support and expertise when Code Orange
events occur.
Anticipate a more accurate account of Code Orange events which possibly may help inform
EHS work in the future
Completed
Completed
Ongoing
Ongoing
References:
Centers for Disease Control (CDC). (2014). National Institute of Occupational Safety and Health (NIOSH)
Study Provides Insight into Healthcare Worker Training & Handling of Hazardous Chemicals.
Occupational Safety and Health Administration (OSHA) (2012)Hospital-wide Hazards- Hazardous
Chemicals, United States Department of Labor
BIDMC Policy, EC-65, Hazardous Waste Collection
BIDMC Policy, NPM 1200-16, Chemotherapy Safe Handling
For more information, contact:
Susan Holland, RN, HealthCare Quality, sholland@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
If you would like more information about this project, contact this person. Make email address clickable.
Susan Holland (<a href="mailto:sholland@bidmc.harvard.edu" target="_blank" rel="noreferrer noopener">sholland@bidmc.harvard.edu</a>)
Project Team
Susan Holland
Aya Sato-Dilorenzo
Christine Powers
Deb Crowley
Department
Any departments listed on the poster or identified in the spreadsheet.
Health Care Quality
Telecommunications
Cancer Center
Environmental Health and Safety
Emergency Management
Materials Logistics
Pharmacy
Environmental Services
MASCO
Shapiro 9 Nursing Staff
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
Collaboration Between Departments to Identify a Gap in a High Risk, Low Volume Safety Process
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
Safety
Timeliness
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/be4aacae76f5a02cbaf75135aba6da47.pdf?Expires=1712793600&Signature=MN-2G7XLoOCNbK-yD7H6UJ9ocOA8Zx0JP7dVqk7FoBRg-uSGZKf5MdL-DGMD-Mzxvdy2oUIpr6dWQUs0rCXKArhdtRSw7Z1l4pTKdBEVppR%7EcxFxM85wMTZ85hykrkebnI8WgltnmmEAS5dO85XHSId6TohcQ-GfG5JVAFbQY-7VpHKYzTX-uncy3PsWKn2RKiaOXjd-9Gs1HOedRaLZ47FNGO89TTYtSsvN7yNmeLbYUoi-Hnum7f5an%7EposAJGCk%7EANqJtGLZi-%7EWPf2TWw80kcieikWE4VU2FWVZAf3ElEKLwjgI7m2f7QTF7wTKNw8NCEKguApMVWUmmFvLSIA__&Key-Pair-Id=K6UGZS9ZTDSZM
02c8ba701cd379801c96ddcbad970895
PDF Text
Text
Clinical Research Response during COVID
Gyongyi Szabo, MD, PhD, Andi Hernandez, Tanya Santos, Michelle Beck, Kim Chun, Chris Botte, and Angela Lavoie
BIDMC
Introduction/Problem
Research Operations needed to quickly prepare a coordinated and safe response to the reduction of
hospital activity in the early response to COVID. It was important to ensure that the safety of research
participants on ongoing therapeutic trials while enabling a rapid implementation of COVID-related
therapeutic trials. Clinical research is conducted across the medical center. Implementing change would
need to be coordinated with department leadership and communicated through different mechanisms.
With guidelines being instituted from hospital leadership, statewide restrictions, and a developing
understanding of SARS-CoV-2, it was essential to have a working group to understand the impact on
clinical research and create guidelines that would align with developing institutional policies.
Aim/Goal
The goal was to effectively manage conducting research during a period of constrained resources and a
statewide lock-down. To address this, research operations instituted several measures to protect
participants and research staff and support important initiatives for COVID research. Just as important as
the response to reduce the research activity to focus on therapeutic trials and COVID was the
resumption of activity in a staged way to allow for a controlled return and coordinated with departments,
clinics, and research teams.
The Interventions
Development of guidelines for the restriction of research activities on-site during the COVID lockdown
Creation of an Urgent IRB Committee for rapid review of COVID research.
Establishment of a Scientific and Institutional Research Review Committee to review the impact of PPE, lab,
nursing, and other clinical resources from research activities.
COVID-19 Steering Committee was established to review new COVID research proposals to promote
collaboration and reduce duplicative efforts and maximize data and biospecimen collection.
Creation of a Return to Clinical Research workgroup to develop a phased re-opening for non-COVID
research. The group was charged with developing a staged plan to reopen clinical research.
Results/Progress to Date
Creation of a COVID dashboard to eliminate patients from being repeatedly approached to participate in
research studies. The dashboard provided real-time updates with impatient data and whether the
participant was approached and/or enrolled into a COVID research study.
The Team
Gyongyi Szabo, MD, PhD, Chief Academic Officer, BIDMC and BILH
Andi Hernandez, Vice President of Research Operations
Tanya Santos, Director, Research Operations
Michelle Beck, Administrative Director, Clinical Research Programs
Kim Chun, Project Manager, Research Operations
Chris Botte, EDC Support Specialist, Academic and Research Computing
Angela Lavoie, Director, Human Research Protection Program
REDCap dashboard created with Academic and Research Computing to facilitate recruitment
communication between different study teams.
For more information, contact:
Andi Hernandez, Vice President of Research Operations
�Clinical Research Response during COVID
Gyongyi Szabo, MD, PhD, Andi Hernandez, Tanya Santos, Michelle Beck, Kim Chun, Chris Botte, and Angela Lavoie
BIDMC
COVID PROTOCOL REVIEW FOR 2020
10, 4%
14, 6%
25, 11%
More Results/Progress to Date
1, 1%
Ceded Review to another IRB
30, 13%
Emergency Use
Exempt
Expedited
Full Board
150, 65%
Privacy Board/Decedent Research
During 2020, the IRB reviewed 230 new research protocols about SARS-CoV-2.
All research staff were assigned a return to research training in myPATH. All key information was shared
in an email announcement, Town Hall meeting, myPATH training and on the research portal page.
Lessons Learned
Any guidelines developed by clinical research needed to align with guidelines from hospital incident
command.
Communication was key to ensure that the information was shared with all the individuals that conduct
clinical research throughout the medical center.
The committees that were established were essential for ensuring that the impact of clinical research
activities was not going to impede clinical operations while allowing for important research to be conducted.
Next Steps
A recruitment postcard was created and handed out at BIDMC COVID testing sites to eliminate the
requests for flyers and recruitment handouts for specific studies. The QR code on the postcard displays all
the current COVID research being conducted at BIDMC and contact information for the study team.
Develop an Emergency Preparedness plan for clinical research using the foundation developed from
these activities.
AAHRPP, accreditation agency for human research protections, has indicated that emergency
preparedness will be a new standard for institutions to meet. We will use our plans used here to
develop our policy and response.
For more information, contact:
Andi Hernandez, Vice President of Research Operations
�Clinical Research Response during COVID
Gyongyi Szabo, MD, PhD, Andi Hernandez, Tanya Santos, Michelle Beck, Kim Chun, Chris Botte, and Angela Lavoie
BIDMC
Steering Committee Members
Steering Committee Members:
• Gyongyi Szabo, MD
• Mark Zeidel, MD
• Richard Schwartzstein, MD
• Howard Gold, MD
• Daniel Talmor, MD
• David Avigan, MD
• Peter Weller, MD
• Kathryn Stephenson, MD
• Michael Yaffe, MD
• Ai-ris Collier, MD
• Nathan Shapiro, MD
• Shahzad Shaefi, MD
• Michelle Beck
• Angela Lavoie
Return to Research Workgroup Members
Re-Opening Workgroup Committee Members:
Andi Hernandez
Michelle Beck
Janet Mullington, PhD
David Avigan, MD
Daniel Press, MD
James Rodrigue, PhD
Peter Weller, MD
Angela Lavoie
For more information, contact:
Andi Hernandez, Vice President of Research Operations
�
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.
Andi Hernandez (<a href="mailto:ahernan1@bidmc.harvard.edu" target="_blank" rel="noreferrer noopener">ahernan1@bidmc.harvard.edu</a>)
Project Team
Gyongyi Szabo
Andi Hernandez
Tanya Santos
Michelle Beck
Kim Chun
Chris Botte
Angela Lavoie
Janet Mullington
David Avigan
Daniel Press
James Rodrigue
Peter Weller
Mark Zeidel
Richard Schwartzstein
Howard Gold
Daniel Talmor
Kathryn Stephenson
Michael Yaffe
Ai-ris Collier
Nathan Shapiro
Shahzad Shaefi
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.
Clinical Research
Research Operations
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
Clinical Research Response 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
Safety
-
https://d1y502jg6fpugt.cloudfront.net/13418/archive/files/ae93d6faa45ba81efb3e665e7911e1ac.pdf?Expires=1712793600&Signature=tRH%7Esnwu7nUixB2ngZPfR%7Enhboy-g0J-DGcJFZqNGdsFADjNkNCnanYbI1mPEZZO5rNqLTnT6nStMKnbpkd4%7EKtEm18RwRIl2M2vuZkHdvo9A7LlGieOeUxC8j9MAfUlAWNYf7Yb835HSRT12fLMl-2p2UTe82HlfRCFGp422BvHvjh4S18HgYqVRvw6B49juvBgiVBZBRH0bXWy4DFc7mtsYKJSmmDa6w48MUh1tKu-FHv86nc1%7EUNiWQsjWJPzUT4Dt4YyTDZ3sSzhhzrFL5gzfzG3W1OLYX2UxxnOIltUhAdcWfVU78b5G765uRw3p1hJNPf-t5ZM6%7Ei6maXwVA__&Key-Pair-Id=K6UGZS9ZTDSZM
f7cff58544b521fbacafb3c2dcaf9bfd
PDF Text
Text
Development, Implementation, and Impact of a Proning Team During
the COVID-19 Intensive Care Unit Surge
Jacqueline Hardman, RN, BSN, CCRN
Beth Israel Deaconess Medical Center - Boston
Introduction/Problem
Prone positioning is frequently used to improve oxygenation in critically ill
patients with acute respiratory distress syndrome (ARDS).
After the surge began, it was recognized that many intensive care units (ICUs)
did not have the resources, education, or experience to prone critically ill
patients.
The MICUs were familiar and comfortable with the procedure of proning, but
many ICUs were not.
Additionally, the process required several members of the patient care team,
which took them away from other tasks, and was time consuming, taking more
than 40 minutes from start to finish.
Aim/Goal
To develop a proning team composed of nurses who were skilled in prone
positioning to maximize efficiency, use resources effectively, and ensure patient
safety.
The Team
Sharon C. O’Donoghue, DNP, RN
Meghan Church, DPT
Kristin Russell, BSN, RN
Michael N. Cocchi, MD
Ari Moskowitz, MD
Jennifer Sarge, BSN, RN
Susan DeSanto-Madeya, PhD, RN, FAAN
Jacqueline Hardman, BSN, RN, CCRN
Margaret M. Hayes, MD, ATSF
Kelly A. Gamboa, DNP, RN, CNOR
The Interventions
A proposal for the development of an ICU proning team was submitted to
HICS
2-hour educational sessions for redeployed OR nurses included an
introduction to the proning protocol and a preproning checklist to reduce the
risk of adverse events
Three education sessions were held and supplemented with an e-learning
module
A standard work document was created to detail the role and expectations
The proning team began working within 1 to 2 weeks of training sessions
12-hour shift support was provided from 8 AM to 8 PM, 7 days a week
The proning team kept a list of patients and would round in the ICUs daily to
assess and discuss proning needs with the ICU nurses
Elements of Proning Team Education and Training
Trainer
Time
Introduction to Proning Team
MICU RN director
10 min
Donning and doffing PPE
MICU RN educator
10 min
General ceiling lift training
SPH team
45 min
Proning training with ceiling lift and practice
SPH team
45 min
Content
For more information, contact:
Jacqueline Hardman, RN, MICU Unit Based Educator, jhardma@bidmc.harvard.edu
�Development, Implementation, and Impact of a Proning Team During
the COVID-19 Intensive Care Unit Surge
Jacqueline Hardman, RN, BSN, CCRN
Beth Israel Deaconess Medical Center - Boston
Preproning Checklist
Results
Adequately sedate and potentially chemically paralyze
Eyes lubricated and taped shut
Perform mouth care & subglottic suctioning
Set up end-tidal CO2 and monitor while prone
Change ECG leads to back
Remove the Foley securement device
Ensure the endotracheal tube is secured with tape
Apply barrier cream to the area around the mouth and under the
nose
The proning team assisted with 3 to 30 patients per 12-hour shift
By having a dedicated role for proning, this maximized efficacy and the proning
team was able to complete the proning and supinating maneuvers in 3 minutes
or less
Between March 5 and May 31, 2020, the proning team assisted with at least
142 turns to the prone position and 169 turns to the supine position.
Evaluate central and peripheral lines/infusions
If possible, flush and cap the arterial line
Place foam dressings on bony prominences and pressure areas
Prone toward the ventilator; position all tubing to ensure a safe
turn
Lessons Learned
If a proning team is to be formed again, the standard work document must be
updated to reflect expectations and clearly define roles to avoid the perception
of “power struggles”
The proning team assisted in additional tasks and should be outlined in the
standard work document
Additional training regarding the preproning checklist, management of the
airway, and proper head positioning would be necessary for another surge
Wound care staff should in-service proning team members regarding
recommendations for positioning, support surfaces, and placement of foam
dressings to prevent pressure injuries in the prone position
For more information, contact:
Jacqueline Hardman, RN, MICU Unit Based Educator, jhardma@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.
Jacqueline Hardman <a href="mailto:%20">jhardma@bidmc.harvard.edu</a>
Project Team
Sharon C. O’Donoghue
Meghan Church
Kristin Russell
Michael N. Cocchi
Ari Moskowitz
Jennifer Sarge
Susan DeSanto-Madeya
Jacqueline Hardman
Margaret M. Hayes
Kelly A. Gamboa
Department
Any departments listed on the poster or identified in the spreadsheet.
Intensive Care Units (ICU)
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
Development, Implementation, and Impact of a Proning Team During the COVID-19 Intensive Care Unit Surge
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
Efficiency
Safety
Timeliness