So we're going to move into our first interactive discussion session. We want to hear from you, your questions and your experiences. So we're going to turn off our cameras here, join you in face virtually. And so there were some questions in the chat. I think Eden has been answering a couple of them, but Eden, if you'd like to share some of the ones that we can try to address here. So we'll start as our first question. And I think it's one that we may come back to is how are analysts funded for the QI team? So how are you, you know, we're moving into this huge amounts of data ingestion, we have access to more data, but how do you sort through it? Yeah, I'll speak quickly here. And I'll be curious to see what Jim, Kelly and Neil have right after. And then, of course, for you in the audience, if you guys have thoughts about this as well, you can put it into the question and answer, we can read it off to the to everyone in the room. So, you know, I work at a big hospital setting. So we have almost, you know, too far away and big of a team of analysts. And our goal as the endoscopy suite is to really, you know, pose our questions and answerable nuggets and have our analysts be able to respond to those requests. So at a big hospital based center, you may have like a team of analysts, you just have to kind of put your requests to and then there might be some turnaround time to get those answers back. But that's where we get a lot of our answers, or questions answered. In our quality improvement team, we also did for some time have our own analysts, and we have like a project manager to help with not just, you know, these sorts of routine metric analysis, but also other projects that we do to try to improve quality and safety. And so we lean on on those resources as well. That's paid for by our division, we do have a big enough division to support that kind of functionality. And I can imagine smaller units might not have the same resources. But I think leaning into whatever larger group you have, and seeing whatever options you have for analyst support is there's usually something, somewhere to lean into. Yeah, I can go Sonali, you know, I might be at the opposite end of the spectrum being in Canada. Um, you know, with respect to having an abundance of resources, you know, it's challenging. You know, we've really had to rely on administration to provide analysts. And it's for the most part, it's it's through the lens in which they want to see it. To be honest, you know, sometimes I even use philanthropy, and patient donation as a tool to fund analytics for patient improvement. So, you know, since Sonali's point, I think you've just got to sort of try to go with the flow, see what you can get out of your hospital, or unit or whatever, you know, center you're doing endoscopy in, and then try to be creative in ways in which you can try to get some analytics out for these sort of endeavors. I'll add Neil, definitely not easy here either. So I agree. But I think the big pitch here is that if your hospital and or the organization that you work with, is invested in having good, you know, outcome measures, you know, everyone cares about their scores, right. And so being able to get the data that you need to improve your scores is just so helpful to their also goals. It's about finding that common ground for what do they care about? And how can you, you know, leverage their goals to get what you want, which is access to data and having analyst support. And oftentimes, you know, if you're able to say, well, you know, our, you know, patient satisfaction scores are just a little bit lower this year, and really want to look into that. Or, you know, if we had a little bit more support and analyst time to do our diagram of where our patient throughput, you know, time goes, we might be able to do x number of cases more per week, you know, being able to build some of those business cases can also be really helpful in getting that analyst support. So Jim, the question from the audience is how are analysts funded for your QI team, we talked a lot about the importance of data, and a very smart question of like, how do you get support to do it? Well, how do you get support to do it? Fortunately, we do have dedicated personnel within the Institute that are responsible for accumulating and mining data that we need. We also are fortunate to have individuals dedicated to monitor both caregiver and patient satisfaction, so that these are readily available. While, you know, they're not up to date, there's a little time lag in the analysis of the data, they are available. So dedicated resources is a must to be able to have the available data for performance improvement projects as well as for satisfaction surveys. We've heard from one member of the audience has shared, if there is a data collection team, my experience is that they don't have patient care experience. So they see one side of the numbers, they need to include voices from the patient care team members to flesh out the discussion. I love this comment. So, you know, thinking back to frameworks of quality improvement, you know, one of the very commonly used models is Lean Six Sigma or the Lean Thinking Model. And so I, you know, I welcome everyone to Google it and find out more. But one of the key concepts there is to go to the Gemba. It's focused on some ideas from Japan. And that just means go to the worksite. And I think you're right, when people are looking at data from a different institution, don't necessarily see the floor. It's hard to interpret, you know, what those numbers mean. And so, you know, as Neil was saying, difference between scope out time and out of room time, like those are very different things. And someone just looking at stamps might not understand that. So you're absolutely right. There needs to be a bridge between the people who are in the unit and physically understand what the numbers may mean, and the people helping you get that data. And so that partnership is really key. I'll acknowledge this takes time and effort and, you know, investment. But hopefully that investment you're able to prove to the people who can give you that data, or even for yourself if you're funding it, is worth it, because you learn so much and are able to improve so much more by getting some of those data and be able to focus on some of your metrics. I think one challenge is, you know, we have a lot of folks from ASCs on the line. So if anybody wants to raise their hand or write their experience in the chat, probably different resources and experience for those of you who are out in ASCs versus being hospital-based in terms of available resources. So feel free to chime in. Our next question is, how do you monitor and assess turnover times, wait times, et cetera? What systems do you use to make those calculations? Yeah, I can briefly answer what experience I have with that. And I'm curious to see what other people have done as well. So we have Epic as our EHR. You can actually get those timestamps out of Epic with the help of someone who has the ability to get it, depending on how your Epic is organized. But you actually can get, like, whenever the nurse clicks, or at least our center, the nurse clicks when the patient comes in the room and clicks when the meds are given, because they have to be documented. And so you can get those timestamps out of Epic, and then you can get it for a patient or for a procedure. And then you can basically get an Excel spreadsheet of those and analyze it in whatever software you would like. So it is retrievable. I think for us, delay is always, you know, who is getting it and how much time is it going to take to get that from an analyst, because there's so many requests and things made. There are other tools in Epic to try to get it yourself. Manually, you can just look at every patient chart, but obviously that's too time intensive to be realistic. But there are other tools in Epic that you might be able to maneuver, depending on how your Epic is kind of organized. Does anyone else have any other thoughts? And then if not, we'll move into one of our case discussions. Yeah, no, exactly the same for us. You know, we can essentially get it through our electronic medical record in the hospital. And then things like wait times, we have through our electronic medical records for our own staff group or GI group. I mean, another option is if you don't, if you can't get it for every patient that's been done over the course of the year, you know, would be to get a snapshot, you know, in one day, see what's happening to the movement of a few patients, at least get some sense of what your, you know, what your current status and see if there's something that you want to move on. For example, if all the nurses are saying, we feel like we're spending too much time, you know, getting our patients ready before they go in. Maybe just have, you know, one of your leader, leadership people spend a half day looking and seeing how much time it is. And actually just take a time or look at it, you know, really spending time at the bedside can be so helpful for understanding some of the real details for why things happen. Not realistic to do for a long period of time, but really, you know, getting some of that firsthand knowledge, and then you can use that to target some interventions and things. All right, great. So maybe this is a good time to flip into one of our case discussions. I'll read this through, and then I'll ask our other faculty here to chime in for what they think. So John is referred for colonoscopy for bloodness stool for the past few months. He is told the schedulers from GI will reach out to him to get it scheduled. He waits about six months, and then he has his PCP appointment, and he asks about it, and the PCP calls GI directly, gets it scheduled for him. He is found to have a large tubular villus adenoma, which is removed. So worked out with timing just by a smidge, right? His friend Cindy called and got her scheduled within a month. She spent a total of two hours on the phone through multiple calls, but made sure her case was prioritized and scheduled. She had a colonoscopy five years ago with no findings, but was told to come back in five years, so she made sure that it happened. How can we schedule based on priority of indication, and can we make the process more equitable instead of based on who can advocate for themselves? So I think in this story, you can see Cindy may not have even had a guideline-based indication for doing it, but she had the time to spend on the phone, and he knew to call, whereas John was maybe told he didn't have to call. We actually struggle with this at our site a lot and have been trying to figure out how to dedicate our schedulers time to make more outgoing calls based on indication, but this is definitely a really challenging process. I mean it's much easier to answer the phones that are coming in as opposed to know who to call out to and make those prioritization lists, so we really struggle with this, and I'm curious what other other sites do. So Neil, what do you guys do at your place? Yeah, you know, trying to do this I think at a unit level would be extremely challenging. You know, something that we're endeavoring on trying to do is actually a centralized waitlist through our physician group, essentially so that patients are streamlined with respect to their indication. You know, all of us receive separate referrals for own subspecialty areas, which we sort of drive, but for general endoscopy and specifically emergent endoscopy through emergency department referral and stuff like that, we try to attempt to triage that, and normally we put the doc who's coming on call on the triage system, so essentially they can facilitate these procedures when they come on call for their week. So that's essentially how we try to do it. It is by no means a perfect process, so I think it's really a challenge that we face in everything. It's just like if you get referred to a central triage versus an individual endoscopist, there may be variants in that as well, so it's challenging. That's a really great point. I mean, for a lot of our sites, I imagine it's not just the patients you see in clinic, but the open access, right, who are not necessarily even triaged. I mean, we have a hard time being able to triage those cases, and we just get requests, and you know, who knows if it's indicated or not or if it's something that we would think is urgent versus not. It's hard to really tease that out because we don't get all that information when the PCV puts in the referral, but we're trying to figure out how to get that, you know, more streamlined and incorporate. Kelly, I'm curious if you guys know. I agree that this is something very difficult, but I'm curious to see how AI might be able to help us with something like this in the future, maybe just simply going by diagnosis codes, and maybe there's a way that we can use that. I don't have the answer, but I'm curious to see how we can involve AI with this in the future. Yeah, that's a great point. I did get somebody chimed in on the Q&A. We use an urgent pool, quote-unquote, mostly cancer-related, EUS for pancreatic mass, etc. These are prioritized. Yeah, that's great, and we try to, we have in our order system, you can say, do you need it to be done? You can say if it's diagnostic or screening, but of course, you know, it's up to the person putting in the order if it's accurate, and then you can say within three days, which is almost never, you know, what happens. That's an option. Urgent within two weeks, and then, you know, the rest is kind of open, but it puts it on the person requesting the procedure to know, you know, how to prioritize it, and I think that's where sometimes it might get a bit difficult. You know, you might have some who kind of game the system. You'd be like, yep, everybody's urgent, and then others who may not acknowledge, like, oh, this person's feather stool. I should put it as urgent, you know, versus not, so trying to find those diagnoses, as Kelly was saying, I think would be really helpful. We have our lead scheduler just from a couple of months ago, actually, in Epic, trying to screen by the indication and, like, look for diagnostic and then drill down to, like, the word saying anemia and certain words like that, but, I mean, it is really still a challenge, and, you know, this is close to a real case that we had, because, you know, if you have backlogs of, we have thousands of people in our backlog, like, there are probably people sitting with cancer that we're just not getting to, and they're not calling for their procedures, and so it really is a big problem, but a tough one to respond to with the resources that we all have limited. Other thoughts for our next case? All right, great. Yeah, I think we're good for our next case. All right, so the nurse manager has been receiving more feedback from her staff regarding increased frustrations with long work hours due to increased inpatient add-on cases. Subsequently, the endoscopy staff vacancy rate has increased by 15 due to CTMs leaving to take travel assignments. The nurse manager recognizes the increased workload of her staff given the long hours required in the current staffing vacancies. What steps should the nurse manager take to help staff feel supported? So, Kelly, I'm curious if you have thoughts, and then we'll go to Jim and Neil. Yeah, so this is something we've all dealt with before, and I'm remembering the time around the pandemic where the thought of travel was so enticing for all the nurses, and I mean, they were really encouraging nurses to come travel. We'll pay you thousands and thousands and thousands of dollars, and you'll have a great time. Come, come, come, and believe me, people took that opportunity, so during this time is when, as a leader, you really need to be flexible, and there are certain things that we can't necessarily fix, and sometimes that's compensation. Depending on your facility, if you're an academic center, if you're a state center, sometimes you don't have that negotiation aspect at all, so if it comes to vacancy for reasons like that, maybe you can't help with that, but the things that you can help are maybe you can change shifts around. Maybe they're working long hours. Maybe you can change your shifting schedule. Maybe we can switch to 10s. Maybe we can switch to 12s. Maybe we can do a rotation of the late night. So not everybody needs to stay late, but maybe we can make some sort of calendar and switch off. And that could be a good start to help. But number one, ask your staff for solutions because you may not have them. So engage everyone, see what we could try first. That's great. I think it really called back to some of the things you had said before about the importance of employee satisfaction and bringing cookies, I suppose, that doesn't solve all the costs, other things aside with the lower pay, but at least- It's easy. Something from the audience. So perhaps staggered shifts may help in this situation. For example, having an early team, late team, and on-call team, this balances quality of life. Yeah, we have something similar for our nurses as well. It's still really difficult. I imagine that a lot of, and I'd be curious what you all think. We've just had a huge kind of incremental, but then like large increase in the number of inpatient cases that we're being asked to do. And so we've had to really change our flow. It's really tough, I would imagine, for smaller hospital systems, and it still is for us. I mean, because the finances of it are really difficult. It takes longer time to do an inpatient case, and yet probably our view generation is the same or lost because it's an inpatient situation. So it really is difficult to figure out how to make, to balance the finances as well sometimes in situations. But I think acknowledging the data of like it's increasing cases and they're taking more time and stuff like that and being able to monitor that, I think is helpful in trying to come up with some solutions as well as asking this time. Jim, thoughts from your end? Oh, no, I totally agree. When you look at having to augment and enhance the staffing of a unit, the cost-benefit ratio of providing creative staffing schedules and allowing incentive and incentivizing individuals to pick up extra shifts in that are paramount. It also goes a long way as providing, as Kelly said, a cookie day, there's also the lunch day or a pizza party day or something to reward the crew for chipping in and carrying it through these low-staffing moments. Thanks, Jim. Neil, thoughts on your end? Yeah, I think just echoing the statements from Kelly and Jim, right? Like, so step one, obviously creating an environment that like, you know, that where people want to help. Now, obviously it can't be pervasive. Like you can't be running late every single day and expecting your team to be happy with that always happening, but the one-offs, you know, creating that culture where everyone just buys in. And as Jim mentioned, like something in our unit we do is we create a one-off, as Jim mentioned, like something in our unit we do is we buy lunch for the nurses or that the team essentially every week is like a group lunch, which I think is just a nice little thing to do. And then potentially looking at or appraising, you know, for instance, the volume of inpatient procedures and try to adjust for that on on-call weeks. And so we try to carve out time, at least ideally on a day-to-day basis for our on-call, because we sort of switch on one week on and then off, you know, try to find times that are scheduled for tackling these inpatients. So those are the things that we sort of use in our own unit. Yeah, great. I will say we've had, because of our increase, we've gone back to our hospital to say, you know, we all know that these cases, when they get bumped the next day, this is increasing hospital stay, like this is bad for the hospital, bottom line, you know, let's negotiate and figure out how we can make this better for everyone and be able to get more resources put towards doing those inpatient cases. Because, you know, as Neil pointed out, there's a difference between one-offs here and there that you try to make people, you know, people are usually willing to help. That's a great thing about people in medicine, but you don't wanna take advantage of that, you know, day after day. And so looking for ways to take this experience, put some data to it and bring it back to some people, maybe in a bigger system that can help you get the resources that you need to meet the demand of what's happening here, right? Because there's this increased demand. We don't have the supply for it. We need to figure out how to make that match better. Let's figure out ways so that the nurses don't have to do longer hours and actually get our cases done on time and accommodate appropriately. That's more like a long-term solution as well as a, you know, short-term ways to try to make people comfortable and happier with some of the things that may happen day to day. So, go ahead, Eden, did you have, did you wanna bring us through here? I have a question for Dr. Sonali, Pete and Dr. Neil. Do you have regular shifts for staff on weekends or do you only have call coverage? So I have the experience of two different hospital systems. So I'll say at my prior institution at Penn, we actually didn't have routine cases being done on the weekends. We had people who were on call and always available to do cases as well as nurses who were there and texts, you know, everyone was kind of, there's a call system, but we didn't routinely go in and do cases. But here at MGH, we have so many cases that it's just routine to go in on a Saturday and a Sunday. So we have like an assigned regular shift for physicians, nurses, texts to be there on both the Saturday and the Sunday. And actually I'll say last year, up until last year, Sunday was urgent cases only, but because we were going in literally every week, there was, you know, unhappiness about that among the staff because it wasn't counting as a normal shift. So just last year, we changed it so that Sunday is a regular shift and it counts accordingly in terms of people meeting their hours and stuff like that. And I think that was actually a big satisfier for the staff. Neil, how does it work at your place? Yeah, so we only do on-call cases on weekends. And so it's only for essentially like inpatient or emergent or like urgent outpatient dossiers that you're facilitating. We've thought about even expanding as a tool for expanding endoscopic volume of having regular outpatient days on weekends, but we've never moved to that. So essentially, yeah, for us on weekends, it's just on call. Oh yeah, that's a tough, we also don't do outpatients, but we have so many inpatients too that we do them on the weekends. Sometimes Saturday is a catch-up day from all the scopes that couldn't get done during the week because we have kind of the space to do it. But yeah, I'm sure it really depends on what the volume is at different centers. Neil, what about foreign bodies in the esophagus? How do you manage, is that just your on-call team goes in for that? Yeah, like most of the time, I don't think many of us would get referrals for foreign bodies from an outpatient perspective. It'd probably be driven through the inpatient service. And so generally speaking, we're doing foreign bodies through the inpatient service. Great. And there was one more question, or I think comment from Mark. It says, include the MDs. I think talking about culture, they spend a lot of time in the rooms with staff. The MDs help drive the culture. That's a really great point. I think, you know, as we talked about, really as a team sport, we want all members of the team really driving it. Neil, it sounds like you guys fund the cookies or the lunches. So it's everyone kind of participating and acknowledging that everyone on the team is working really hard. That's really great. We move to our third case. All right. So we've talked about actually kind of this through some of our talks and a theme. So a Spanish-speaking patient arrives to the endoscopy unit for a screening point accompanied by a family member who also did not speak English. The registration associate did not speak Spanish and was unsure of how to communicate with the patient and her family member. What should be done to remedy this situation and for the future? So I'll comment about what happens at our institution, but I'll vary the order here of our faculty. I think we'll go with, I can't remember what we did in the past. We'll do Jim, Kelly, and Neil. Oh, gee. So thank you. And a individual, let it be Spanish or Ukraine, when they present for endoscopy, we usually have the patient demographs available that we have able to contact interpretive services. We have, if an actual interpreter in person is not available, we'll do and provide interpretation services by either a phone service or through a iPad. We do have very staff of various nationalities that have gone through our global patient services and have been certified to be able to act as interpreters themselves. If there is no available interpreter, either through these three means, and we need to have a staff, I mean, a family member act as an interpreter, it can be done on the physician's opinion, as long as it's well documented for them to serve as the interpreter. Thank you, Jim. Before coming to Kelly, actually, I'd love to hear from any of our people in the audience, if you're working at a smaller unit, how do you manage these sorts of situations? In our unit, we also have a phone line and we have a team of interpreters, as well as the programs we can call into. So that's kind of become standard because we have, in our institution, it's 10% of our patient population speak something other than English. And so we have to have all the languages available by phone, if not by video conference and such. And so it's a very common occasion for us. But I am curious what happens, and I think across the world, we're seeing with a movement of people that this is a very common scenario. We wanna make sure that we have things put in place outside of what can be kind of managed on the day of. So Kelly, what are your thoughts here? So an important note for pre-op phone calls. So I'm sure most of your facilities are making these calls at some point prior to the case. It would be a good thing to know preferred language. So Spanish, at this point, we should probably all be able to at least introduce ourselves in Spanish. That's a very nice and considerable thing to do. So I would really, for a language like Spanish, which is really so common, at least the ability to say that you're the nurse or whoever you are and say hello in Spanish, something very simple. But yes, own interpreting service, video interpreting service, an actual live interpreter, and definitely instructions, discharge instructions, prep instructions, and consent all should be translated into Spanish. And those services are available. There may- Oh, Kelly, you're just muted for a moment there. And there are some services where you can send those documents directly out and they will use medical interpreters to change out your instructions. Yeah, thank you. Before we get to Neil, we'll see what some of our attendees have said. So we have interpretive services on an iPad. This iPad follows the patient through every step of the process, procedure, pre-op, procedure, room, and post-op. Patients like this and feel at ease. That's great. Another person says we have iPad interpreter 24-7. We must use it if in-person is not available. So that's great. I think that is probably the standard for a lot of centers. You know, I was thinking back to one of our attendees who said they're a one-person ASC, and like, that's a lot tougher to have some of these services available, but hopefully everyone's being able to buy into these sorts of things. Neil? Yeah, similar to your guys' experience. I guess the one thing that might be a little bit unique is that we have, like, programmatic clorical cancer screening in the province. And so therefore, like, there's this robust interpreter service that's attached to that. So normally you can tap into that service. So there's all these interpreters around. So that's a really nice thing that we have up here, but yeah, essentially, you know, try to track down an interpreter through your hospital or a telephone service is normally will be our first approach if that's not available. Maybe I'll pivot this to another question I'm curious about. So, you know, prep instructions, obviously super important to have in the language, language congruent to the patient. Go lightly, I believe the pharmacy is able to provide in Spanish, but we have large Vietnamese population, Mandarin population, and those don't exist. We worked really hard these past couple of years to update and have available some of those documents in five languages. Haitian Creole is another growing population. So we got to translate into that, but we don't have it in every language. So I'm curious, what do you guys do for prep instructions? What do your schedulers do? If it's in a language that you don't have your instructions in? So going backwards order, Neil, Kelly, Jim. I'd have to bug them. No, my suspicion is they probably try, like a lot of times, especially because that's for me, more of an outpatient issue. You know, my medical offices will commonly use with family members to walk them through it, I suspect. That'd be my guess on what she does. Trying to find some way in which you can get clear communication for prep instructions, because we all experience that that's the worst when someone comes in and they just not understood how to do the process. And so it's a missed opportunity for a procedure and obviously it delays their procedure. Yeah, yeah. We've tried to put more pictures into ours. It's not quite an Ikea model, but at least put some pictures to see if it can help. But it really is tough. Kelly, what do you guys do at your center for prep instructions in different languages? Yeah, so if a patient needs additional time, the structure usually is we would have somebody, a secretary or unit clerk make the initial phone call. And if it's a little bit more time consuming, and I don't mean to say consuming, but if we know that it'll take additional time, then we would have an LPN or a nurse take the time and use a translator. So, and really get that speech back and make sure that the patient repeats and understands the prep and that can be done all through translator services. It's just, we know it takes additional time. Yeah, talking through. And also it's like, were they able to listen and understand all the details? There's so much involved to say, take this med, don't take these meds, all sorts of things. So that really is tough. Jim, what does your group do? Well, our experience has been that we're fortunate. I forget how many languages that the prep is in now. I know it's half a dozen at least. But if there is the chance that a patient needs to have instructions translated for them, we do utilize a interpreter service to do that. We have a registered nurse who's the clinical care coordinator, and she will contact the patient and coordinate the interview with the interpreter to ensure that the instructions are understood. Wow, that's really fantastic. I'll bring back a comment about the domains here. So you were talking about something that's to make the impacts of several domains, actually having the prep instructions and having someone able to speak in the language of the patient insight is necessary to be patient-centered and also affects the effectiveness of the care, right? We also know it impacts efficiency both positively and negatively, but I wanna acknowledge that there are downsides to supporting all these different aspects and makes it really difficult in that it does take more time. I think we all know that when the endoscopy unit can be effective if you have several people speaking a different language because you have to wait for the interpreter to repeat back and work through. I think we all feel the moral imperative to do so, but I wanna acknowledge that this is one of those scenarios where all the domains, like the pie is only so big and we have to figure out what to prioritize. And I think we all end up working it out so that we prioritize the resources knowing that this impacts patient-centeredness and effectiveness and acknowledge that there is sometimes increased cost and time dedicated to do it. And the best we can do is try to come up with methods that streamline it the best that we can like having resources set up ahead of time and things like that to try to make it better. It's really nice when I happen to have the tech who speaks Brazilian Portuguese for our Brazilian Portuguese patients because it's so much easier, especially when putting the patient at ease when you're putting the person in position and stuff like that. But it would be great if everyone spoke all the languages of the world and that's harder to come by. All right, great. Question, do your inpatients get go lightly? Oh, I'm so curious to hear what people say. At our institution, actually we switched to doing SUPREP because it's lower volume and we just have such a hard time getting inpatients to be prepped on time that we switched to SUPREP and did find and actually I think published a couple of years ago about how that improved time to procedure as well as prep during procedure. But then there were concerns about renal dysfunction and we give them new lightly instead. We have a paper coming out soon on how it doesn't seem to be an issue and probably SUPREP can be used on everybody. And it's more about like, again, negotiating the improvement in the effectiveness and the prep quality. And it doesn't seem to be a negative in terms of safety for the renal dysfunction question. I'm curious what you guys do. So Kelly, I'll let you go first of all. I don't know actually if you do a lot of inpatients in your prior institution or here. Oh, yes, absolutely. So it was, believe it or not, we did mainly MiraLAX for outpatients and the physicians preferred that, but because of a pharmacy ordering issue on the inpatient side, we did use Golightly. We did, that was, yes. I'm going to follow up a question because during the Golightly shortage for outpatients, we also had done MiraLAX and of course there's a suggesting it's about the same but we found that preps were not as good. I think because people just weren't drinking enough other material, there were issues with understanding how to do the prep as opposed to standardized injections for Golightly. So we actually flipped back to doing Golightly for outpatients. A big other factor was equity, just the cost because people had to pay for MiraLAX out of pocket and Golightly is covered. You're right. And also the splitting of the prep drives a significant amount of questions and phone calls and then patient nervousness because they're not sure what if I'm an hour late? What if I'm two hours late? Can I, do I have to wake up in the middle of the night to take the second part? You know, there were a lot of questions but that was how my previous facility did that. And I'm still learning with USC. It seems like there's a mix of prep so far. So I'm not quite sure yet, but this is good information. Yeah, I think it was Neil who can go next about inpatient preps as well as outpatients. I think both are interesting. Yeah, so outpatient preps is individualized for the endoscopist. I don't think we have, we've tried to standardize it to some degree. I think most of us as well as alongside inpatient preps are still using like four liter peg-based valve preparations. Individualized, wow. That's a lot for the schedulers to keep track of. And Jim, what happens at your institution for inpatients and outpatients? Yeah, inpatients, we're still using the go lightly prep for inpatients. Most of it's due to the concern of the patients who may have altered states of metabolism that we don't want them to have adverse events. For outpatients, like Neil has shared, we have a cornucopia of physician-driven preps that are used as well. Each one has their likes. So it is a logistical nightmare for schedule staff and coordinators, but for the most part, it seems to work. Yeah, very interesting. We've tried so hard to try to make it like one standard prep. And then people may have preference. They'll ask for the Miralox, they'll ask for SUPREP. We have an extended prep, but we wanted to make sure the schedulers had one folder of preps to go to and then had the translated versions. It'd be really hard to find a Haitian Creole translation of one individual endoscopist prep. At least that's what we've struggled with. It's always good to hear what works at other sites as well. Yeah. Another question in. We are a small ASC. How do you triage, quote, difficult IV starts, end quote, when we do not have an IV team or Doppler capability? Thoughts on that? What a great question. I'll start with Anil on this one, because I know you mentioned you had a team and then we'll go to Jim and then Kelly. Yeah, tricky. Like if you don't have an IV team that you can call on or alternatively have Doppler capabilities, I'm not aware of any literature, but it's definitely not my expertise on like what predicts a difficult IV start. You know, if I was in a smaller center like that, I probably would just try to base it off of previous experience. So if patients have an identified difficult IV start, I'd be asking for them to come to the procedure like earlier to see if we can get access so that it can still continue, you know, patient flow. And then alternatively, I guess, if you're operating in different centers, potentially allocating those types of patients to centers that have those capabilities. We have the Doppler capability. But we do still end up with people with IV start difficulties. I think perhaps the biggest difference for us, and I think our surgical unit would agree, was that when we moved from NPO at midnight to drink their liquids until a couple of hours before the scheduled procedure, I think that actually had helped dramatically. I had overheard many of the nurses being like, oh, finally, you know, what may have been a difficult start in the past because the people were dehydrated, now it's a little bit easier. So that might be something that helps decrease the number of people with difficult IV starts, but of course doesn't cover all the scenarios. Jim, your thoughts. Well, for us, this problem is slowly waning away due to the fact that anesthesia support is present in the majority, vast majority of our units now. So not to say that they're the expert IV stickers, but they bring along the demand to have dobblers and all those other vein finding technology available. Though for the few centers that don't, most of the patients really identify with our pre-calling if they are difficult IV starts, or have had difficulty with anesthesia or sedation in the past. So this is earmarked on there in the EMR, just like allergies are. So we know to triage and schedule them in an appropriate department. Wow, Jim. So do your schedulers ask every patient about difficulty with IV access? It's part of the checklist when they schedule procedures. Interesting. Kelly, your experience. And I'll also ask anyone in the audience, if you wanna write in what you guys do at your centers, I think that'd be helpful to everybody. Yeah, I think that's excellent that you have that capability with your EMR. We do not have that, but what I will say is there's always a unit expert or IV superhero. So I would just make it a policy, never attempt more than two times on a patient, especially an outpatient. This is an elective procedure for the most part to make sure you have your tips and tricks all sorted out. You can use hot packs, you can warm the patient with a few blankets. If you see, they look a little cold, their veins don't look like they're popping out too well. There are little things that you can do, but I would just have a workflow around making sure you give that patient a good experience and not giving them too many sticks. Also- It sounds like actually, oh, sorry, go ahead. Oh, no, no, go ahead. Also, if you have the capability of maybe a vein finder, those little devices have a small footprint and work pretty well. So that would be an option. Yeah, I want to see how Jim's unit tries to identify ahead of time so they can devote their resources, which is a very helpful aspect. And Kelly, you're saying have things in place, assuming anybody might be a tough vein to find, so both together actually are really great, both for the ones you can identify and then when you have trouble and you weren't even expecting it. So that's really helpful. Here from our audience, Morgan writes in, we are a small unit, our schedulers ask and will ask difficult IV to arrive earlier to allow for more pre-op time. That's great, yeah, wonderful. All right, we have a few minutes. We have another case. What do you think, Eden, do we have time for it? Yeah, we have five minutes, let's do it. All right, so as the nurse manager checked on her staff in the endoscopy unit, she saw that biopsy specimens from the patient's EGD were still on table listing gastric biopsies at 38, 36, and 34. She knew that the patient had a history of barotasophagus. The patient was undergoing a subsequent colonoscopy and she realized that the specimens had not been verified before the next procedure was being done. The unit has been short-staffed for the past few months and during this time period, multiple specimen collection errors have occurred. What should be done? All right, I forget what order we were in, but we'll go Jim, Kelly, Neil. Oh, gee golly. So let's gastric biopsies at 38, 36. Okay, so not that we're perfect either. Specimen labeling errors do occur. So what can be done in the meantime is that the specimen is taken care of. She knows it's there. We verify with endoscopists that these are specimens from the esophagus and they'll just go ahead and be processed accordingly. What can be done in the meantime is that we have a collaborative effort between the medical staff as well as the nursing staff, procedural staff that universal protocol stipulates that specimens are reconciled at the completion of the procedure, even if it's a combo procedure, we make sure that everything is labeled and placed into the proper jar and is bagged and tagged before moving on to the second part of the procedure. So that's what we do. And we do have a, I don't know, we call them anymore a fast track committee to help identify any of these problems. And I don't wanna say there's penalties for not doing it though. You know, there are expected performances for caregivers and some staff, it has been punitive, but I've heard that they may be alternate to not having morning endoscopy slots anymore. So I don't know. Oh, wow. I mean, I think what's really nice about the acknowledgement in this case is that it was short staff. Like I think, you know, not so much that it was maybe one person's poor knowledge, but it could have just been, they're just so busy that they weren't listening and they're, you know, trying to document many things. And so I think part of it is trying to find what led that person to the mistake, but also what are the system drivers into this, right? So I think both are helpful. If you have one person who, you know, seems to be making more mistakes, maybe the question is like, oh, do they, you know, do they know how long the esophagus is usually? And maybe we should give some basic understanding of that so that they're less likely to make this sort of mistake again. But more likely it's probably just like they were trying to do multiple things at the same time. We need to make sure that we dedicate the right time to do the timeout that Jim's talking about, which I think is routine. All right, so Kelly, your thoughts. Yeah, so for any irreplaceable specimen, you should have some sort of workflow policy. And sometimes it may appear that a specimen was sent correctly. And then later on the lab says, this looks like this is tissue from the stomach, but you're labeling it as colon. So, and these types of things happen. So when they do, you really have to do a drill down and see who's in the room, what's going on, what is, is someone breaking away from normal workflow? But with a specimen, it should always be labeled right away, patient's name, all the verifiers should be checked, the medical record, date of birth. If you have an account number or some sort of encounter number, all of those things would need full verification. So that person should really be whoever is in the room, but, and it should be discussed during debrief at the end of the case. And the debrief should be very clear. We have four specimens, read them out and say they're going to be delivered to pathology. But that part should be done during debrief at the very end of the case. And then as in terms of the verifier, if it can't be someone in the room because of a busy turnover or next case coming, then at least another licensed professional should be verifying and reading back to the person who was in the procedure room. It takes time, but we think that it's worth it in terms of the safety and the effectiveness of the procedure, yeah. Neil. Yeah, I think echoing Jim and Kelly's comments, I think having that debrief and maybe allocating to someone in the room to actually walk through the debrief out loud, I think it'd be really helpful. So in my unit, it'll be me who does it. Essentially sort of going like, this was what we did, this was the procedure, this is the sedation we gave, you know, we have a pain score. And then, you know, essentially like, where did we take samples from? These are the samples that we've taken and then sort of confirming patient labeling and stuff like that. And so I think just getting that into the flow of the procedure, I think, you know, nothing's perfect, you know, these things can happen, but hopefully we'll mitigate it to, you know, a good degree. Yeah, wonderful. Also, I love how the nurse manager was checking on our staff and listening in and trying to understand these problems. I mean, I think that's so important, right? Having leadership kind of be present and aware of what's happening so they can try to problem solve in real time and generally. So as we go into the break, I'll just add Candice's voice to this. She writes in, always use closed loop communications. And with that, Dr. Palachaudry, I think we're ready for our first 15 minute break.

healthcare

endoscopy

data analysis

patient communication

quality improvement

language barriers

patient-centered care

collaboration