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Quality Improvement Project for Patients Requiring MRI with Anesthesia at OHSU Douglas Arditti, M.N., M.S.N., FNP, CRNA Peter Schulman, M.D. APOM Grand.

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Presentation on theme: "Quality Improvement Project for Patients Requiring MRI with Anesthesia at OHSU Douglas Arditti, M.N., M.S.N., FNP, CRNA Peter Schulman, M.D. APOM Grand."— Presentation transcript:

1 Quality Improvement Project for Patients Requiring MRI with Anesthesia at OHSU Douglas Arditti, M.N., M.S.N., FNP, CRNA Peter Schulman, M.D. APOM Grand Rounds January 26, 2015

2 What is the average delay for the time an MRI is scheduled and the actual time it begins? How long does it take to start an MRI after induction of anesthesia? What is the average anesthesia time for an MRI? 74 minutes (range: 28-116 minutes) 31 minutes (range: 6-93 minutes) 116 minutes (range: 51-272 minutes)

3 Project Description »OHSU Department of Anesthesia & Perioperative Medicine (APOM) & OHSU Department of Diagnostic Radiology-MRI »Analyze causes of delays for adult undergoing MRI with anesthesia »Efficiency & safety Improve staff satisfaction Identify safety hazards

4 Anesthesia in the MRI Suite »Non-OR anesthesia presents unique challenges »MRI Suite Hazardous Environment –Safe anesthesia care requires specialized equipment and procedures Sequence/protocol for scan often lengthy (2-5+ hours)

5 Analysis: What are we doing now? »Process mapping Technique for making work visible Identifies sequences of activity and decision points Reveals areas where potential bottlenecks or delays occur AHRQ. Developing a high-level process map and swim-lane diagram. http://www.ahrq.gov/professionals/systems/hospital/red/swimlane.html. Updated August 2011. Accessed December 30, 2014. Activities Tasks Steps Start & End Steps Decision

6 Process Map: Ordering an MRI Scan with Anesthesia

7 What factors in our department cause delays? »Fish bone diagram (Ishikawa diagram) Explore potential or real causes that result in a single effect Assists in searching for root causes and identify problem areas Depicts relationships or hierarchy of events Compare relative importance of different causes AHRQ. Building your cause and effect diagram. http://www.ahrq.gov/professionals/systems/hospital/red/swimlane.html. Updated August 2011. Accessed December 30, 2014.

8 Anesthesia Related Delays in MRI Department

9 Eliminate Trips for Supplies Anesthesia supply cabinet located in holding area To be stocked by anesthesia technicians Combination lock installed (same combination as anesthesia cart)

10 What We Learned »Providing anesthesia services in MRI suite requires coordination of many different individuals and departments Lead MRI technologist Radiologist Radiology scheduling OR scheduling Anesthesia D-1 Anesthesia provider(s) Anesthesia technicians Inpatient nursing staff IRU nursing staff PACU nursing staff (sometimes) Transportation services

11 What We Learned »The process for scheduling an MRI scan for patients requiring anesthesia care is complex and inefficient Multiple challenges arise because our EHR (EPIC) interfaces with multiple information systems at OHSU (e.g., OR scheduling, radiology scheduling, billing systems) Inpatient vs. outpatient protocols are very different Stakeholders each had a different understanding of when the MRI scan would actually begin

12 Understanding MRI “Table Time” MRI Table Time Time that the MRI scan will start (analogous to “incision time”) Your schedule in EPIC Now scheduled 45 minutes prior to MRI Table Time

13 MRI Scan Scheduled for 12:00-13:00 Time seen in EPIC Total time 135 min

14 Improving EPIC »For inpatients: Clinicians ordering MRI scans now encounter a “Soft Stop” when placing orders in EPIC Requires confirmation that anesthesia D-1 has been contacted prior to processing the order »Outcome Virtual elimination of Lead MRI Tech involvement prior to D-1 approval

15 Improving Coordination of Team Members »Anesthesia Technician to arrive in holding area 30 min. prior to MRI scan “Table Time” Remain during induction and patient transfer Available to assist with emergence »Holding area to be clear during induction and emergence 15 minutes prior to “Table Time” 15 minutes after MRI scan complete »Prior to completion of scan MRI Technologist contacts IRU (or PACU) and Anesthesia Technician

16 What We Learned »MRI Techs have a different perspective than us »Amongst anesthesia providers, there is often variation in clinical practice »There is an opportunity for team building between our departments

17 Enhancing Teambuilding: Team Pause »Introduction of MRI Tech(s) (MRI Tech) »Confirm planned scan (MRI Tech/Anesthesia) Potential ‘intra-scan’ changes/issues (MRI Tech) »Introduction of anesthesia team (Anesthesia) Attending CRNA/Resident Anesthesia technician »Quick review of plan and roles (Anesthesia) Induction plan Monitoring needs Logistics (transport of patient in and out of scanner) Emergence –Location Special concerns/patient issues/positioning concerns »Confirm reservation for recovery (Anesthesia/MRI Tech) IRU vs PACU

18 Special Equipment »Familiarize yourself with MRI compatible infusion pump and Invivo monitor MRI Tech and Anesthesia Tech can assist with troubleshooting

19 Practice Recommendations: Work flow »Confirm that AGM and monitoring equipment is functional; check suction equipment in Holding Area (Zone II) »Team Pause »Induction Monitors: Use MRI compatible placed at foot of trolley O 2 : Use wall source with O 2 extension tubing »Transport to Scanner Switch O 2 source at Zone IV entry (or place on AGM) Positioning supervised by anesthesia provider Anesthesia cart moved to Zone III »Exit Scanner Anesthesia cart: Move to Holding Area (Zone II) Monitors: Transfer patient using the MRI compatible monitor Switch O 2 source at Zone III entry Emergence from anesthesia in Holding Area (Zone II) Transport patient to IRU/PACU with transport monitor and O 2 E-cylinder

20 APOM-MRI QI Project Team Team Leader: Douglas Arditti, MN, MSN, FNP, CRNA (Instructor, APOM/Student, University of Washington DNP Program) Team Members: Wayne Smith, ARRT RT (Supervisor, MRI Department) Michelle Greenberg (Support Services Manager, Radiology Scheduling) Joseph Bussiere (Lead MRI Technologist) Mike Burrell (Lead MRI Technologist) Project Sponsor: Peter Schulman, MD (Director OOR Anesthesia-APOM ) Project Liasons: Tina Foss, MHA (Surgery Scheduling); Dawn Anderson (Surgery Scheduling); Liza Kamps (Senior Project Specialist-EPIC); Matthew Davis (Supervisor, Anesthesia Technicians); Tara Menon, RN (IRU Nursing Manager); Laurie McKeown, MD (Program Manager, Patient Safety); Rob Miller (APOM-System Application Analyst), Executive Liasons: Jeffrey Kirsch, MD (Chairman-APOM); Stephen Robinson, MD (Clinical Director-APOM); Fergus Coakley, MD (Chairman-Diagnostic Radiology), Brock Price (Director-Radiology Department)


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