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

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

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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

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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

#

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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

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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

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Volume at “INTERNAL” Sites

0

1000

2000

3000

4000

5000

6000

7000

EASTShapiroWEST


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Volume at “INTERNAL” Sites

0

1000

2000

3000

4000

5000

6000

7000

EAST Shapiro West

2002

2003

2004

2005

2006

2007

2008

2009*


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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


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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*


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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)

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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


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% Inpatient Echo Volume (%)

37

38

39

40

41

42

43

44

45

2002 2003 2004 2005 2006 2007 2008 2009*

%


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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


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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


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


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3D Echo Studies

0

150

300

450

2005 2006 2007 2008 2009*


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TEE Volume

0

150

300

450

6002

00

2

20

03

20

04

20

05

20

06

20

07

20

08

20

09

*


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TEE Volume (West/East)

0

10

20

30

40

502002

2003

2004

2005

2006

2007

2008

2009*

East


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Stress Echo Volume

0

200

400

600

800

1000

1200

1400

1600

2001 2002 2003 2004 2005 2006 2007 2008 2009*


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Stress Echo Volume

0

200

400

600

800

1000

1200

1400

16002002

2003

2004

2005

2006

2007

2008

2009*

Shapiro


WJM 06/09

Stress Echo Volume

0

20

40

60

80

100

120

140

1602002

2003

2004

2005

2006

2007

2008

2009*

East

West


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?

Documents

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