1. WJM 06/09 BIDMC Echocardiography Laboratory: “State of Our Echo Lab” July 1, 2009

2. WJM 06/09 In memoriam: Vaia Nutter October 25, 1957 – June 25, 2004 “Having a quick wit and an infectious laugh, she captured the hearts of many” Boston Globe 6/30/04

3. WJM 06/09 Vaia Nutter Scholarship Sonographer at BIDMC for 8 years Committee: –Linda Walsh, Marilyn Riley Akil Winchester, Susan Yeon, WJM Bunker Hill Community College Sonography School – Individual undertaking sonography as a second career Financial need Recipients –2006 recipient - Julie Graham –2007 recipient – Jean Doricent

4. WJM 06/09 Franz Aepfelbacher Award (Excellence in clinical care, research education, and humanitarianism) Native of Germany, Research at Oschsner, Cleveland Clinic BIDMC Fellow 1998-2002 (Non-invasive imaging) Outstanding/talented clinician, educator, researcher –2001 AHA Outstanding Fellow in Cardiology Special Recognition Award Oregon post-fellowship (appointment at Oregon Health Sciences) After long illness, died 2009, leaving wife and 3 children 2009 recipient – Airley Fish, MD (!)

5. WJM 06/09 PEOPLE Attending Staff : Warren J. Manning, MD * (Section Chief) Evan Appelbaum, MD * James D. Chang, MD * Loryn Feinberg, MD * Eli Gelfand, MD * Yuchi Han, MD * Joseph P. Kannam, MD * David O’Halloran, MD * Susan B. Yeon, MD, JD * *Passed ASExam special competency exam 20 years 4 years 2 years 3 years 14 years 11 years 0 years

6. WJM 06/09 Attending Reading

7. WJM 06/09 Sonographers : Marilyn F. Riley, RDCS (Chief Sonographer) Ron Abrams Janet Bailey, RDCS Dorota Bzymek, RDCS Deamie Estabrook, RDCS Kim Fanning, RDCS Deborah Fuller, RDCS Martha Jackson, RDCS Julie Graham Linda Walsh Marianne Johnson, RDCS (PT) Don Rogers, RDCS (NAVIX-CH, Chelsea, Lex) Steve DiSalvo, RDCS (Premier-HSL)

8. WJM 06/09 PEOPLE Administrator: Daniel Ibanez Reception/Scheduling: Carlissa Windett (W) Akil Winchester (E) Iris Wasserman (E) Financial: Dina Crosta-Moran Incoming 3 rd Yr Echo/TEE FELLOWS : Riya Chacko, MD Francesca Delling, MD Airley Fish, MD Ali Mahajerin, MD Nisha Parikh, MD Ali Rahimi, MD Alena Goldman, MD David Leder, MD Amit Thosani, MD

9. WJM 06/09 Goals 1.Highest quality echo examinations & interpretations 2.Advanced Certification of staff MD: American Board of Echocardiography exam Sonographer: RDMS/RDCS 3.Fellow training/teaching 4. Research/innovation

10. WJM 06/09 2008/09 Accomplishments David O’Halloran passed Echo boards Airley Fish – Franz Aepfelbacher Award New long-term storage solution (RAID) Expansion of 3D (October 2008 3D Training Day) Initial involvement of echo staff with ICE (Eli Gelfand) Implemented weekday ED/Inpatient stress echo on WEST East Campus TEE on Stoneman 3 Increased echo research visibility Biweekly case based imaging conference (2 nd /4 th Friday; 12:30pm) New LCD monitor for Baker 3 teaching New floor in Shapiro and East scanning rooms, East hallway EchoPAC Upgrade to BT06 Monthly Friday noon sonographer case conference

11. WJM 06/09 BIDMC Echo Lab Clinical 3 Major/5 Satellite Sites –WEST Campus – inpatient TTE/TEE, “emergent” outpatient Saturday sonographer scanning (7 studies – 2-3 outpatients/4-5 inpatients) –SHAPIRO – “elective” outpatient TTE/stress echo Thursday evening (2 rooms; 4:30, 5:30, 6:30pm) –EAST Campus – “urgent” outpatient, inpatient Inpatient TEE (Stoneman 3) Chestnut Hill (Thursday) – DVD (download by sonographers, MD destroy) Lexington (Tuesday) – DVD (download by sonographers, MD destroy) Chelsea (Friday) – Image Vault Hebrew Senior Life (any day; prn) – DVD (download by sonographers, MD destroy) –Copley – JPK, DVD (download by sonographers, MD destroy)

12. WJM 06/09 Total ECHO Volume *Extrapolated; fiscal year 10/1-9/30 #

13. WJM 06/09 ECHO Volume Growth # *Extrapolated 7/1/00 – 6/28/09; fiscal year 10/1-9/30

14. WJM 06/09 ECHO Volume Growth % *Extrapolated 7/1/00 – 6/28/09; fiscal year 10/1-9/30

15. WJM 06/09 Volume at “INTERNAL” Sites *Extrapolated; fiscal year 10/1-9/30

16. WJM 06/09 Volume at “INTERNAL” Sites *Extrapolated; fiscal year 10/1-9/30

17. WJM 06/09 Volume at “EXTERNAL” Sites *Extrapolated; fiscal year 10/1-9/30

18. WJM 06/09 Volume at “EXTERNAL” Sites *Extrapolated; fiscal year 10/1-9/30

19. WJM 06/09 Attending Volume/Day Chelsea, Lex, CHill go next day reader Sunday West and East go to Monday reader

20. WJM 06/09 Sonographer Staffing Inpatient (East and West) –Accommodate 80% of inpatient TTE requests ordered by noon Outpatient goals –Accommodate “emergent” requests – 24 hours (WEST) –Accommodate “urgent” requests – 72 hours (EAST) –Accommodate “elective” requests – 7 days (Shapiro) 6/29/09 STRESS Wait List (7/14/09) TTE Wait List (7/21/09)

21. WJM 06/09 EAST Campus East Inpatients (4 Mon/Fri; 3 Tues-Wed-Thurs) At noon sonographer assesses inpatient volume If inpt requests cannot be accommodate by the next day (e.g., more inpt requests than that afternoon or next day inpt slots) Call Marilyn/WC sonographer to come EAST EC sonographer stay late (up to 2 cases) as OT

22. WJM 06/09 Inpatient/Outpatient Echo Volume *Extrapolated; fiscal year 10/1-9/30

23. WJM 06/09 % Inpatient Echo Volume (%) % *Extrapolated; fiscal year 10/1-9/30

24. WJM 06/09 Portable Echo Volume *Extrapolated; fiscal year 10/1-9/30

25. WJM 06/09 Contrast Echo Studies *Extrapolated; fiscal year 10/1-9/30

26. WJM 06/09 Definity Echo Contrast WARNING: Serious Cardiopulmonary Reactions Serious cardiopulmonary reactions, including fatalities, have occurred during or following perflutren-containing microsphere administration – Assess all patients for the presence of any condition that precludes DEFINITY administration (see CONTRAINDICATIONS) –In patients with pulmonary hypertension or unstable cardiopulmonary conditions, monitor vital signs, electrocardiography, and cutaneous oxygen saturation during and for at least 30 minutes after DEFINITY administration (see Warnings) –Always have resuscitation equipment and trained personnel readily available. DEFINITY product warning 5/08 (revised from 10/07)

27. WJM 06/09 Focused Echo Studies *Extrapolated; fiscal year 10/1-9/30

28. WJM 06/09 3D Echo Studies *Extrapolated; fiscal year 10/1-9/30

29. WJM 06/09 TEE Volume *Extrapolated; fiscal year 10/1-9/30

30. WJM 06/09 TEE Volume (West/East) *Extrapolated; fiscal year 10/1-9/30

31. WJM 06/09 Stress Echo Volume *Extrapolated; fiscal year 10/1-9/30

32. WJM 06/09 Stress Echo Volume *Extrapolated; fiscal year 10/1-9/30

33. WJM 06/09 Stress Echo Volume *Extrapolated; fiscal year 10/1-9/30

34. WJM 06/09 Wednesday Morning Conference Coordinated by Evan Appelbaum CME credit (MD and sonographers) Begin promptly at 8am ’09-’10 schedule posted on the web “Teaching” Tab –Topic is “flexible”; “Swap dates” with others [notify EA, Akil, WJM] MD/Sonographer meeting – 4x/yr 1 st Wed every other Month (Aug, Oct, Dec, Feb, Apr, June) –Sonographer meeting 8-9am – Dana 4 Fishbowl –MD meeting; 7:30-8:30am, East Campus Library –ICAEL case review 4x/year WJM meets 7:30am: 1 (MD); 2/4 (1-2 yr fellows); 3 (TEE fellows)

35. WJM 06/09 Fellow Expectations (web) Level 2 qualifications (ASE/ACC documents) TTE –150 scans/300 interpretations over 2 yrs (5 non-invasive months) –Mornings – scanning (25-30/month) Complete ENCOR prelim on cases they scan (after 2 wks) –Afternoons – reading (30 + cases/wk) Teaching Resources: –Otto text for each fellow (new edition July 2009) –S drive (digital echo teaching file, echo board exam, etc.) –Echo Web Site –Division EchoSAP Laminated scanning cards Complete evaluation of attending staff Support IV saline/Definity contrast injection Attend/participate conferences (Mon advanced imaging, Monday clinical, Wed Echo, Wed Nuclear, Fri CGR/noon cases)

36. WJM 06/09

37. MonTueWedThurFri 7:30-8am1- MD/sono 2/4-1/2yr 3-3 nd yr 8-9amClin Conf Echo Conf CGR 9:30- 10:30am Nuclear (TH) 11-12pmCMR 12-1pm CMR/CC T/ Nucl ECG (AG/MJ) 12:30-1:30 2/4:Imag 1-2pmNuclear (TH) 4-5pmCCT (TH) Nuclear (TH) CCT (TH) Fellow Conferences EAST WEST

38. WJM 06/09 Echo Lab Web Site Attending Schedules Sonographer Schedules Protocols [TTE, TEE, Dobutamine, Definity, etc.] Teaching/Fellows [Fellow expectations, echo references, Wed am conference, fellow presentations] Forms [Echo Fax, Sonographer prelim, TEE prelim, TEE consent, Wed am Conference sign-in/eval] References [Aortic/Mitral prosthesis, BIDMC Quant guidelines, diastolic dysfunction, Definity, ASE links]

39. WJM 06/09 ENCOR Now in use for >9 years, quite stable ENCOR at Needham –Distinct database, but in “sync” with BIDMC ENCOR If there are answers that you would like to use, or other changes, please e-mail me

40. WJM 06/09 TEE Fellow Responsibilities (see Web Site) TEE fellow –~2 mo TEE (>100 studies) –TEE document on the web –On-call for TEE months –Back-up TTE; TEE –Conference presentation –M&Ms –Firm conference –Wed am case/presentation –Friday 12:30pm cases –Monday Clinical conference support –Save interesting/classic avi (movies); jpeg (stills) –Flag “teaching” files in ENCOR (with reason)

41. WJM 06/09 Shapiro Fellow Responsibilities Shapiro Fellow –Arrive by noon on the day the scans are acquired –Interpret scans using ENCOR –First week – focus on TTE/ENCOR –subsequent weeks – focus on all stress echo (>15 studies/day) –List “fellow reader” –“SAVE” as “Preliminary Report” and PRINT prelim report (OMR) –Put report with sonographer preliminary –Attending staff will interpret and write comments –Comments will go in Shap 7 “Fellow over read bin” Save interesting/classic avi (movies); jpeg (stills) “Flag” teaching files in ENCOR (with reason)

42. WJM 06/09 Attending Staff Responsibilities Advancement to ASE Competency Exam WEST staff – no other commitments, primary teaching site –Full time, TEE in a.m. [9,10,11am on Farr 4] WEST/EAST/HSL – echoes read same day Shapiro/Lexington/Chelsea/Chestnut Hill – read the next day East reader – TEE, emergent same-day Shapiro reads Shapiro reader – Read on assigned day; provide fellow feedback Fellow feedback (monthly evaluations) Attend and participate in Mon/Wed am conf, CGR, Fri noon Contact referring MD/HO [phone/e-mail as appropriate] for any unexpected findings [mass, AS, LV dysfunction, PEmbolism, positive stress etc.) Contribute to research and teaching mission of the Division Save interesting/classic avi (movies); jpeg (stills) “Flag” teaching files in ENCOR (with reason)

43. WJM 06/09 Shapiro Reading Etiquette Assigned Shapiro Reader of the day has priority for the countertop workstation

44. WJM 06/09 Sonographer Responsibilities Arrive to begin the day at the assigned time –7:30am sonographer checks for changes in the schedule “Late sonographer” prepares for next day (print/post schedule, pull tapes, print old studies) Follow BIDMC protocols Continuing medical education –Support for acquisition of RDMS/RDCS, Wednesday a.m. conference Prioritize studies for reader Pull and set old tape studies (E,Sh, W, Chelsea, Lexington, Chestnut Hill) Print old reports for reader and put with tape or prelim form Fellow teaching (West Campus) Ongoing suggestions for lab improvement 3D training Before leaving – check to be sure data in ENCOR and transferred to ImageVault “Flag” teaching files in ENCOR (with reason)

45. WJM 06/09 Next Year: Goals Sonographers –Maintain health and retain current staff (add TWO sonographers – Vaselina/NAVIX) –Reconsider potential 10 hour work-day for some sonographers (?Shapiro/?West) –Improve lab morale –Increase sonographer RDMS/RDCS Attendings –ICE training for 2-3 attendings –Emphasize/build on teaching (S: drive cases) –Expand primary research activities Equipment –Replace Vivid i on WEST and SHAPIRO with Vivid q –Replace Acuson Sequoia on Farr 4 with Vivid q with ICE –Obtain Real-time 3D TEE echocardiograph system General –Add Needham digital images to our Echo ImageVault –Add ICE answers to ENCOR –Migrate ImageVault Jukebox to RAID storage –Increase stress echo scanning on Shapiro to two rooms 2 days/wk –ICAEL recertification (AS, stress echo cases) – DUE 12/31/09 –Survey outpatients on service (in process) –Integrate “Journal Report” to Wed am conference –? WebEx for Wednesday am conference (CVI Echo sites) –Start Wed am conference on time (!) –Welcome Michael Chuang (!)

46. WJM 06/09 Thank YOU! Attending Staff : Evan Appelbaum, MD James D. Chang, MD Loryn Feinberg, MD Eli Gelfand, MD Yuchi Han, MD Joseph P. Kannam, MD David O’Halloran, MD Susan B. Yeon, MD Fellows: Michael Chuang, MD Joyce Meng, MD Francesca Delling, MD Xin Yang, MD Jan Pattanayak, MD Sonographers : Marilyn F. Riley, RDCS (Chief sonographer) Ron Abrams Janet Bailey, RDCS Dorota Bzymek, RDCS Deamie Estabrook, RDCS Kim Fanning, RDCS Deborah Fuller, RDCS Julie Graham Martha Jackson, RDCS Marianne Johnson, RDCS Linda Walsh Support: Akil Winchester Carlissa Windett Dina Costa-Moran

47. WJM 06/09 Questions/Comments?