wjm 06/09 bidmc echocardiography laboratory: “state of our echo lab” july 1, 2009
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WJM 06/09
BIDMC Echocardiography Laboratory:
“State of Our Echo Lab”
July 1, 2009
WJM 06/09
In memoriam:
Vaia NutterOctober 25, 1957 – June 25, 2004
“Having a quick wit and an infectious laugh, she captured the hearts of many”Boston Globe 6/30/04
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
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 (!)
WJM 06/09
PEOPLEAttending 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
WJM 06/09
Attending Reading
0
20
40
60
80
100
120
140
EA JC LF EG YH JK WJM DO SBY
2008/09
WJM 06/09
Sonographers:
Marilyn F. Riley, RDCS (Chief Sonographer)
Ron AbramsJanet Bailey, RDCSDorota Bzymek, RDCSDeamie Estabrook, RDCSKim Fanning, RDCSDeborah Fuller, RDCSMartha Jackson, RDCSJulie GrahamLinda Walsh
Marianne Johnson, RDCS (PT)
Don Rogers, RDCS (NAVIX-CH, Chelsea, Lex)Steve DiSalvo, RDCS (Premier-HSL)
0
0.5
1
1.5
2
2.5
3
0-3 3-6yr 6-10yr 10-15yr >15 yr
Sono
WJM 06/09
PEOPLE
Administrator: Daniel Ibanez
Reception/Scheduling: Carlissa Windett (W) Akil Winchester (E) Iris Wasserman (E)
Financial: Dina Crosta-Moran
Incoming 3rd Yr Echo/TEE FELLOWS:
Riya Chacko, MDFrancesca Delling, MDAirley Fish, MDAli Mahajerin, MDNisha Parikh, MDAli Rahimi, MD
Alena Goldman, MDDavid Leder, MDAmit Thosani, MD
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
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 (2nd/4th 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
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 echoThursday 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)
WJM 06/09
Total ECHO Volume
10000
11000
12000
13000
14000
15000
16000
2001 2002 2003 2004 2005 2006 2007 2008 2009*
*Extrapolated; fiscal year 10/1-9/30
#
WJM 06/09
ECHO Volume Growth
0
100
200
300
400
500
600
700
800
900
'01 to'02
'02 to'03
'03 to'04
'04 to'05
'05 to'06
'06 to-07
'07-08
'08-'09
#
*Extrapolated 7/1/00 – 6/28/09; fiscal year 10/1-9/30
WJM 06/09
ECHO Volume Growth
0
1
2
3
4
5
6
7
'01 to'02
'02 to'03
'03 to'04
'04 to'05
'05 to'06
'06 to'07
'07 to'08
'08-'09
%
*Extrapolated 7/1/00 – 6/28/09; fiscal year 10/1-9/30
WJM 06/09
Volume at “INTERNAL” Sites
0
1000
2000
3000
4000
5000
6000
7000
EASTShapiroWEST
*Extrapolated; fiscal year 10/1-9/30
WJM 06/09
Volume at “INTERNAL” Sites
0
1000
2000
3000
4000
5000
6000
7000
EAST Shapiro West
2002
2003
2004
2005
2006
2007
2008
2009*
*Extrapolated; fiscal year 10/1-9/30
WJM 06/09
Volume at “EXTERNAL” Sites
0
50
100
150
200
250
300
350
4002
00
0
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
*
Chelsea
Chestnut Hill
Lexington
Hebrew Sr Life
Copley
*Extrapolated; fiscal year 10/1-9/30
WJM 06/09
Volume at “EXTERNAL” Sites
0100200300400500600700800900
Ch
el
Ch
Hill
Le
x
He
bre
w
Co
ple
y
To
tal
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009*
*Extrapolated; fiscal year 10/1-9/30
WJM 06/09
Attending Volume/Day
0
5
10
15
20
25
30
West East Shapiro
MondayTuesdayWednesdayThursdayFridaySaturday
• Chelsea, Lex, CHill go next day reader• Sunday West and East go to Monday reader
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)
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
WJM 06/09
Inpatient/Outpatient Echo Volume
0
1000
2000
3000
4000
5000
6000
7000
8000
90002
00
0*
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
*
InptOutpt
*Extrapolated; fiscal year 10/1-9/30
WJM 06/09
% Inpatient Echo Volume (%)
37
38
39
40
41
42
43
44
45
2002 2003 2004 2005 2006 2007 2008 2009*
%
*Extrapolated; fiscal year 10/1-9/30
WJM 06/09
Portable Echo Volume
0
400
800
1200
1600
2000
2400
28002
00
1
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
*
East
West
*Extrapolated; fiscal year 10/1-9/30
WJM 06/09
Contrast Echo Studies
0
50
100
150
200
250
300
350
400
4502
00
2
20
03
20
04
20
05
20
06
20
07
20
08
20
09
*
SalineOptisonDefinity
*Extrapolated; fiscal year 10/1-9/30
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)
WJM 06/09
Focused Echo Studies
0
150
300
450
600
750
*Extrapolated; fiscal year 10/1-9/30
WJM 06/09
3D Echo Studies
0
150
300
450
2005 2006 2007 2008 2009*
*Extrapolated; fiscal year 10/1-9/30
WJM 06/09
TEE Volume
0
150
300
450
6002
00
2
20
03
20
04
20
05
20
06
20
07
20
08
20
09
*
*Extrapolated; fiscal year 10/1-9/30
WJM 06/09
TEE Volume (West/East)
0
10
20
30
40
502002
2003
2004
2005
2006
2007
2008
2009*
East
*Extrapolated; fiscal year 10/1-9/30
WJM 06/09
Stress Echo Volume
0
200
400
600
800
1000
1200
1400
1600
2001 2002 2003 2004 2005 2006 2007 2008 2009*
*Extrapolated; fiscal year 10/1-9/30
WJM 06/09
Stress Echo Volume
0
200
400
600
800
1000
1200
1400
16002002
2003
2004
2005
2006
2007
2008
2009*
Shapiro
*Extrapolated; fiscal year 10/1-9/30
WJM 06/09
Stress Echo Volume
0
20
40
60
80
100
120
140
1602002
2003
2004
2005
2006
2007
2008
2009*
East
West
*Extrapolated; fiscal year 10/1-9/30
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
• 1st 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)
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)
WJM 06/09
WJM 06/09
Mon Tue Wed Thur Fri
7:30-8am 1-MD/sono
2/4-1/2yr
3-3nd yr
8-9am Clin
Conf
Echo Conf
CGR
9:30-10:30am
Nuclear
(TH)
11-12pm CMR CMR
12-1pm CMR/CCT/Nucl
ECG(AG/MJ) 12:30-1:30
2/4:Imag
1-2pm Nuclear
(TH)
4-5pm CCT(TH)
Nuclear(TH)
CCT(TH)
Fellow Conferences
EASTWEST
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]
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
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)
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)
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)
WJM 06/09
Shapiro Reading Etiquette
• Assigned Shapiro Reader of the day has priority for the countertop workstation
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)
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 (!)
WJM 06/09
Thank YOU!Attending Staff:
Evan Appelbaum, MDJames D. Chang, MDLoryn Feinberg, MDEli Gelfand, MDYuchi Han, MDJoseph P. Kannam, MDDavid O’Halloran, MDSusan B. Yeon, MD
Fellows:Michael Chuang, MDJoyce Meng, MDFrancesca Delling, MDXin Yang, MDJan Pattanayak, MD
Sonographers:
Marilyn F. Riley, RDCS (Chief sonographer)
Ron AbramsJanet Bailey, RDCSDorota Bzymek, RDCSDeamie Estabrook, RDCSKim Fanning, RDCSDeborah Fuller, RDCSJulie GrahamMartha Jackson, RDCSMarianne Johnson, RDCSLinda Walsh
Support:Akil WinchesterCarlissa WindettDina Costa-Moran
WJM 06/09
Questions/Comments?
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