David Hambrick, BSN, RN, CGRN GI Nursing Director Dallas, TX When Emergencies Arise in the GI Lab...

David Hambrick, BSN, RN, CGRN

GI Nursing Director

Dallas, TX

When Emergencies Arise in the GI Lab…Who you gonna

call?

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Objectives

1) Describe potential GI patient specific emergent situations

2) Describe adequate preparation and response techniques for GI patient-specific emergent situations

What Admin & patients think GI staff look like

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What we really feel like

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Emergencies in #MyGILab?

It’s more common than one would think

Emergencies are not confined to just the procedure room, often occur during off-unit procedures

Regardless of setting, emergencies can happen throughout the peri-procedural continuum

Occur in hospital & ASC based units

What is a GI Endoscopy Emergency? Definition depends on several factors…

Overall patient presentation Significant co-morbidities Intra-procedural complications Presence of Specialists incl Anesthesia

Also depends on: Who you ask (Internist, GI, Surgeon) Time of Day, Day of week, Discharge status Availability of physician, their clinic/office time

and/or a 0700 open room tomorrow morning

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Our Definition of Patient Emergency “An unexpected situation requiring an immediate

response in order to prevent or minimize undesirable patient complication or outcome” D Hambrick, 2015

Bleeding, Hypo/hyper tension Malignant hypertension (est 0.00001% GA cases)

Equipment malfunction Worsening patient condition despite intervention

May also include: Facility related issues (power loss, fire, etc) Staffing availability Internal/external disaster scenario 7

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Disclaimer time This presentation is to review unit preparation for

Emergencies, not clarification of the definition Each facility’s Medical Staff/GI Lab Committee has to

set up expectations for: Response time for emergencies Patient conditions requiring emergency

intervention Who responds to emergency procedures

(anesthesia) Quality/Performance metrics associated with

utilization of on-call/after hours atff

Most Common (Clinical) GI Emergencies

Acute Abdominal Pain

Gastrointestinal Hemorrhage

Biliary Tract Obstruction

Hepatic Failure (Variceal Bleed)

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The GI Lab is Everywhere

Ideally, emergent procedures are handled in the GI Lab, M-F, 0700-1500, but…

Emergency Room

Intensive Care Unit

Operating Room

“The Floor”

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Leadership Responsibilities Scope of practice review to determine potential

emergent procedures

Staff competencies and practices must be reviewed to identify potential failure points

Coordination with ancillary Leadership and staff for expectations of emergency response Anesthesia, Radiology, ICU, ED, Periop, Lab, Blood

Bank, etc

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Okay, so what does that mean to us? All staff responding to GI emergencies must be

competent in the expected treatment modalities Different depending on practice settings ASC vs Community vs Academic

All staff performing a role in emergent GI procedures must be trained to standard/competency with regular re-validation or demonstration

All equipment required for scope of intervention must be available & servicable 24/7

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Standardize the Process All unscheduled/urgent/emergent procedures should be

handled the same way Starting with notification of the GI Lab staff, have one

way to do it, regardless of day, time, procedure Have a standardized report form, including

Pt ID (two identifiers, name DOB) Pt location Procedure to be performed Location of procedure (ICU, ED, GI Lab, etc) Expected time of procedure Other services needed (Anesthesia, blood bank, pathology, etc)

The Safest Way to Do Anything…

Benefits of standardizing the process:

Eliminate problems with mis-communication, direct calls to staff from physicians to nursing/tech staff

Education of physicians, Fellows, Nursing/Tech staff conducted, documented, part of Orientation

Ensures equipment, devices, etc are present and available for use

Ensures trained & competent staff present Process should go through Governance process, accepted by

GI Lab Committee to ensure compliance

Let’s Do It Right the First Time

Usual scenario:

It’s 0115 on Tuesday night, the GI Fellow calls the cell phone of GI Tech/Nurse on call:

“We need to do an EGD, patient is in the ED waiting on an ICU bed. GI bleed, need to do it ASAP, let the on call nurse & anesthesia know, thanks <click>”

What Could Possibly Go Wrong?

The GI staff now has to figure out: Name, location of patient, where the patient will be

when they arrive

What type of GI Bleed? Variceal? Foreign body damage? Hematemesis? Gastric? Rectal bleed but r/o upper GI cause? Post-surgical?

What equipment is needed?

Is anesthesia available? Have they been notified? Are they necessary?

Recipe for Disaster…

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The Staff tries to figure it out… So, they:

Call other on-call staff, give general patient info Go to hospital, grab everything based on personal

experience Spend 30 minutes tracking down where the patient is, find

out that Anesthesia wasn’t notified Go to patient location, start procedure, realize you don’t

have what is needed, case is delayed while running back to the GI Lab to find it

Meanwhile: The patient care is delayed Physician is frustrated Everybody gets yelled at the next morning

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Replay using Standardized Process

The physician notifies the hospital operator to page the on-call staff, creating a log entry to review in case of performance variances

On-call staff responds to page, calls physician to get patient and procedure information

Using standardized report format, receives all pertinent information including:

Pt ID (two identifiers, name & DOB) Pt location Procedure(s) to be performed & special equipment needed Location of procedure (ICU, ED, GI Lab, etc) Expected time of procedure Other services needed (Anesthesia, blood bank, pathology,

etc)

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Once the Team is on site…

All team members meet at the agreed upon procedure location

All requested or expected equipment is present

All ancillary staff is prepared per protocol Staff demonstrates competency in equipment and device set-up

and use

Procedure is performed, optimal patient care is delivered

Nobody is yelled at the next morning

Recognize the Need Recognize the Need Recognize the need

How to Standardize the Process

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How do we do that?

Present objective data to GI Governance team to demonstrate change is required to improve patient care, outcomes, physician, patient, staff satisfaction

Identify shortcomings in staff education and procedural competencies using:

Formal competency evaluations

Feedback from staff, physicians

Data elements from scheduling and procedure reporting

software

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Then what?

Develop standardized exectations for each role Use task specific training plans based on identified

shortcomings for all roles

Use standardized Best Practice training & processes to minimize staff performance variances

Using (unit experts, vendor clinical experts) train staff to competency, documenting competency in employee files

Establish feedback mechanisms between staff, physicians and leadership (GI Lab Committee) on improvement processes and outcomes

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Let’s wrap it up

There’s one standard of performance to competency regardless of time, location or duration or procedure

All team members are to be trained to competency and then required to perform to that standard

Variances in the process are identified, trended, and corrective action taken as required

Expecting untrained, incompetent staff to perform to standard is harmful to patient outcomes as well as staff and team development and cohesiveness

Questions?