So now it's my pleasure to welcome back one of my Hopkins colleagues and introduce another. Joining Mary Rose Hess for the next talk on strategies for better educated patients is Rose Fusco. Rose has spent the last 33 years of nursing at Johns Hopkins Endoscopy where her focus has been a safety champion, a facilitator, and colon cancer awareness advocate. Mary Rose, Rose, the audience is yours. Thank you, Mary Rose, for inviting me today to do this and your encouragement. Mary Rose and I will be presenting on strategies for better educated patients, the art of improving bowel prep scores and mitigating no-shows. So, I have no financial relationships to disclose. Bowel prep inpatient strategies. My discussion points will be communication, robust use of media, adaptive scheduling, prep salvage, failed preps, and then Mary Rose will discuss future of bowel preps. So, communication is key. Throughout the day, we have frequent communication between key players, the fellows, the floor team, including the primary team and the nurses, the facilitators. We have a prep or front of the house facilitator and then we also have a intra-op facilitator that manages the procedure rooms. So, communication is key as Dr. Eisenberg stressed in his talk this morning. We also have updates and status on the prep so that adjustments can be made in real time and efficiently. And we have outreach activities to the units to encourage open dialogue and tips and tricks that help for improved coordination as well as education on the importance of adequate prepping. So, here we just have some photos of doing outreach and teaching our colleagues. We do lunch and learn. We have a dedicated card that we can take to the units and we'll sponsor a breakfast or a lunch and then just have dialogue with the bedside nurses. And food is always definitely an incentive. So, we do robust use of multimedia. So, this happens continuously throughout the day. The floor nurse will send chats and image files directly to us, to the team and the facilitators at the chat if there's any question on the quality of the prep. The images give immediate objective unbiased feedback on the quality of the prep. So, we are continually like talking. I may even run back to the procedure room and speak to the fellow and say, what do you think? Does it look okay? Because, you know, we want to be, you know, we want to be smart with our time and that we feel like, you know, every minute counts. And I'll be presenting a case study. So, this was an inpatient colonoscopy. This patient is a 41-year-old with interstitial lung disease diagnosed in 2012 at 29 years of age when she developed acute shortness of breath. She had worsening respiratory symptoms requiring 15 liters of oxygen at home, therefore beginning her pre-lung transplant workup. And she needed a screening colonoscopy. Then there was an incidental finding of a rectal mass on PET scan. So, before I continue, I just wanted to give you a little bit more summary of the five months prior to when she came to us in January, which I think it's important to appreciate that journey and workup. So, in August, she had a PET scan that showed the sigmoid mass, nodularity, and thickening. Then she was admitted in September and had a colonoscopy, no luminal mass. Then in October, she had a flex EUS. It was limited by inability to pass the scope, no visible mass. Then IR attempted the biopsy. It was technically challenging, only one pass that revealed fibromuscular tissue and chronic inflammation. Then in December, she had the repeat CT that showed this extra luminal mass. It was stable in size compared to the PET scan in August. Then she presented in January for a further workup. So, as you know, PrEP clarity was crucial. So, this is a real epic chat that happened. So, she prepped from Tuesday to Friday. Of course, because of all her previous diagnostic workup, there was going to be a new approach. So, it was important that she be extra clear. So, she started on Tuesday, and throughout the week, there were multiple chats, and no, she wasn't clear enough. So, I just wanted to go over this epic chat between the endo team and the floor team. The floor nurse, this is what she looks like. Then the fellow, that looks pretty good to me. Then the endo fellow again, where are we going down here? Then the primary doctor, I have not been so excited all morning. And then the endo fellow, amazing, it's a go. Then the primary doctor, thank you all, truly a journey. Then finally, the floor nurse, love it, woohoo. So, I have to say this slide captures just so much emotions. It captures the determination, perseverance, persistence, and hard work of the team. And then again, this picture is worth a thousand words, because she was very clear. So, the follow-up summary, then that was the morning with that picture, because she continued prepping. So, she came in the afternoon, and I actually was the nurse that prepped her. Just very nice, very nice patient, had a lot of compassion for all that she had gone through. So, the approach this time was going to be with one of our therapeutic physicians, Dr. Kashab. If anybody could do it, we felt like he could do it. He was going to try this myotomy approach, because it was an extra little mess. So, there was significant volume of serosal fat. The visualization was obscured. There was limited scope mobility that prevented entry into the peritoneal space. And unfortunately, the procedure had to be aborted. She was discharged, I'm sorry, on January 17th, she had surgery. She had a sigmoid colectomy and colostomies. And then she was discharged on the 24th, with a diagnosis of adenocarcinoma of the sigmoid colon. So, I did a deeper dive. I wanted to just kind of see if I could find more information. And actually, then the mass had been diagnosed as Brzee-Dorfman disease, which is a benign histiocytic proliferative disorder. And she currently is undergoing still routine lung transplant screening. So, wish her well. Adaptive scheduling. So, this involves triage and continuous rebalance of the schedule to accommodate optimized patients. So, again, this involves the, you know, the team approach of just communicating via epic chats, just face-to-face conversation. It's an ongoing process. It relies on input from all stakeholders to ensure that the maximum number of patients get done within their daily operational hours. We want to decrease downtime. We want to maintain utilization. And again, every minute counts. And so, we are continuously having conversations with the inpatient team. Factors including medical status, level of care, and other interventions and procedures all are considered. So, some examples are we have a high cardiac population that have LVADs. And so, currently, we provide cardiac anesthesia on Tuesdays and Fridays. So, that's an important factor that patients are prepped and done on those days. Because if they have to be canceled and re-prepped, then it's challenging to then coordinate cardiac anesthesia. If they have, if they're on dialysis, then we encourage dialysis to be done first in the morning so that we could do them in the afternoon. So, of course, our goal is to, like, salvage these patients, you know, poor preps. And what do we do with failed preps? So, with the inpatient population, if the prep is not optimal, then we give an additional two liters. It can be administered up to two hours prior to the procedure. And of course, then we still have to maintain, you know, our operational, we want to do this within our operational hours. If unsuccessful, the team will reschedule the patient for the following day based on patient priority. Our goal will then be to, you know, put them early in the morning. We partner with our outpatient colleagues, and we can't do this on a frequent basis because of the doctor's blocks. But oftentimes, if an outpatient will be identified as a poor prep, we oftentimes then will try to give them more prep the rest of that day, and then either reschedule them the next day with either the same provider or a different provider. That's happened on many occasions rather than, you know, just canceling them all, you know, just canceling them. And I believe I now pass the baton to Mary Rose. Thank you, Rosa. So, I'm going to touch base a little bit about the future of bowel prep and our backlog of colonoscopies and what we're doing to handle this issues, the metrics developed in the QI projects we're currently working on, the collaboration for improving success with our success with our preps in both outpatient and inpatient populations, looking at the development of resources and not recreating that wheel and maybe redeveloping some of our resources we already have. What are our actual education opportunities? Of course, bringing in my secret weapon, Shanshan, for data collection, and specifically looking at how we improve those cancellation, fail preps, increased length of stay of patients and mitigating those no-shows. So first, metric development and QI projects. So as many people have mentioned prior to this presentation that there's a huge backlog of elective procedures specifically for endoscopy, colonoscopies after COVID and hospital required colonoscopies is one of the backlogs that we're dealing with. So what are our QI projects and what can we do to make a difference? And I have to say Dr. Abdi was the first pioneer to kind of grab the bull by the horns and start this ball rolling. She initiated a standby process for her cases to kind of decrease this backlog of patients. She deals with a lot of direct access patients that unfortunately have a high cancellation rate. So she initiated at the beginning that if she had, and I hope I'm right on this and you can correct me if I'm wrong, that if you had less than five DA patients, you got one standby case. And if you have more than five DA patients, you had two standby cases because you knew they would cancel. And you personally were calling, following up with these patients. And we noted, and it made a huge difference, right? In our utilization and bringing in those backlog patients. So we started to add on to take it a little further and start on adding a quality improvement project on Thursdays where we add on two cases. And these cases necessarily don't belong to any provider, but if a cancellation occurs that any provider will have to take that patient that's waiting. And so far we've started this process and we haven't turned any patient away. In addition to that, we opened an additional block to deal with these backlog patients in our suite on Mondays. And we're starting to look at starting another QI project of over booking patients to deal with the backlog and bring other providers in the mix. Shanshan again is developing a metrics for us to follow this. Another big key piece is we're following up with the patients because we want to capture their experience. We don't want to compromise quality of patient care by trying to squeeze as many patients as we can in to deal with the backlog and to care for a huge population that we care for. So besides all the QI projects with our backlogs, we said to ourselves, how can we do more to help? What are our next steps? And where do we go from here? So Dr. Abdi and Eden invited us to present for the ASGE and based on that invitation, it made me think, what can we do more? We always focus in on March on colon cancer awareness and screening. And based on the invitation to present for the ASGE, we said to ourselves, what can we do? What can we do better regarding bowel prep? You know, we're always focused on colon cancer awareness and screening, but let's go back to the basics. How can we improve our bowel prep with our patient population? So we've decided for this March, we're gonna have an event, colon cancer awareness bowel prep bash. And our first step in this process, in this journey, since we've received the invitation to present is we've been collaborating regarding how we're improving the success with our preps for both outpatient and inpatient population. So we started looking at the resources that's provided for education to our inpatient nurses, right? They're the frontline folks that are providing that education and our outpatient nurse population. And then we started looking at what resources are given to our outpatient patient population and inpatient regarding on how to prep appropriately and successfully. And we took and we surveyed a bunch of nurses and some of the patients that have prepped for procedures just to get some data, some feedback to kind of, cause that's our audience to give us some information as a compass to guide us in the right direction. Well, we also started collaborating with pharmacy because one of the biggest issues are the bowel preps that are out there. So we look to find out what current industry and company is providing most of our bowel preps for inpatient and outpatient population. And we're currently working with that company to rebuy some of their preps. And we brought pharmacy in cause we wanna make sure that insurance is covering these preps for our patient population. There is a huge need to improve bowel preps because you can't have seven-year-old grandma drinking four liters of fluid. It just doesn't happen. It's not feasible. So we're looking at realistic solutions and collaborating with those folks that can make those changes on the frontline with us. So again, Shanshan gathered the data. We're gathering up until this March on every failed prep, canceled cases, no shows with our colonoscopies, inpatients and outpatients under the umbrella of Johns Hopkins. And of course, looking at those increase of length of stays in the institutions due to these poor preps. So we're currently in this process of collecting the data up until March. And then the resources we're developing and we're modifying current ones that we have. We're working with the team with that using the Donna Wright competency model to make sure that we're meeting all individual learning needs because we identify that folks learn differently. So we're revising our current written instructions, making sure that they match, outpatient and inpatient instructions match with the preps that are being used. We're making sure that they're on a fifth grade level and providing them for the top languages for our population that we serve here at Hopkins. We're also looking at some video links that we wanna make sure that the videos that we produce are the same links that are being used, outpatient and inpatient and that the same resources are being used for under the enterprise of Hopkins regarding our bowel preps. And then currently we're working with our lead educators in the institution and our EPIC committees here soon. Hopefully we can get this rolling in March with the goal April that anytime patients are scheduled that there's a link of all these resources that will populate immediately for the patients. And currently we're working with our lead educators here at Hopkins to create an avatar for inpatient nurses so they can ask any questions and it will verbally answer those questions back for them. We're currently working on, as I stated, QI projects for scheduling smarter. We're researching what evidence-based practice articles are out there. So this is where we are currently. Our goal is to take from our survey and all this information, those actionable education opportunities and present them at our March Madness Colon Cancer Awareness Bowel Prep Bash. So our audience again is the inpatient nurses and outpatient nurses. Using that Donna Wright competency model, we wanna have some hands-on stations and simulators so they can see that visualization is very important. And if we don't have a clear area to work, then we not only can't screen the patient, if we're removing lesions, we can't do an ESD, endoscopic submucosal dissection, if visualization is impaired. So we're gonna have some hands-on stations so they can get some real life of some of the difficulties and challenges and barriers that we have here in endoscopy. We're also gonna have some education stations. Hopefully we'll make the station at the end of the day. We're working with the company to revise the taste of some of their bowel prep so there'll be a tasting station. Hopefully that turns out good and not bad, but at the end of the day, we're gonna reveal our videos, those links, provide evidence-based practice articles with their handout, and we're gonna reveal our avatar that day. We wanna make this event fun and rememberable. We're gonna have our champion physicians, one speaking every hour with door prizes and gift card giveaways after their presentation. And we're gonna have inpatient unit participation prizes. The inpatient units who have the highest turnout will definitely get a unit prize. We're gonna be putting in a photo booth, making themed bags where folks can fill it with healthy snacks from our wellness bar. And I'm sure our younger nurses will make a TikTok and post it on our event. So after the event, our goal is to follow this data for a year and see, have we made a difference with our bowel preps? Have we made a difference with our backlog with these patients? So I hope that the data will reveal that we're heading in the right direction and we've made a significant difference with our initiatives, for our strategies to better educate our patients and our frontline nurses that are educating our patients and providing them the tools that they need in their toolbox to be successful. And in hopes that our prep scores will improve and we won't have to worry so much about mitigating those no-shows. So this is the event that we're working on. This is where we currently are. We hear an endoscopy. If we see an issue, we take the challenge and this challenge was all based on the invitation to present here today. So we definitely wanna make sure with all these quality improvement projects, the main goal is that we never compromise our patient care and that we're capturing their experience and that we're making sure that we're serving their needs appropriately in our journey to commit to quality care for our patients. So our March Madness Colon Cancer Awareness Bell Prep Bash will occur March 25th at Chevy Chase. Stay tuned for the final results. And I think Rose is gonna close us up with the takeaways. Thanks, Mary Rose. So our takeaways and our communication, we stressed that how important that is with all our stakeholders, robust use of multimedia and those epic chats, how crucial they are, adaptive scheduling, PrEP salvage, how do we save those patients that have failed PrEPs, the backlog of colonoscopies, actionable education, the resources, data collection, and stay tuned for next year as we develop our new tools with our new data collection. Thanks everyone.

educated patients

bowel prep

communication strategies

multimedia use

case study

quality improvement projects