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Archive for the ‘Ultrasound’ Category

Intracavitary Probe Cleaning

A reminder that we have a new, simplified workflow for cleaning the intracavitary (vaginal) probes on the ultrasound machines:

1. When you are finished using the probe, remove the condom cover and wipe the probe down with a paper towel and T-Spray II.

2. Tell the ED tech covering your zone:
A) The probe needs to be cleaned
AND
B) The patient it was used on (they need the patient info for their log book- very important)

3. The tech will then take the ENTIRE machine to the dirty utility room in East Zone so the probe can undergo high level disinfection. They will NO LONGER remove the probe from the machine. They will wipe down the entire machine while it is there. When the cleaning cycle is complete, the probe will be covered with a blue bag and the entire machine will be returned to its proper room.

The big change is the probes will not be removed from the machines. No more lost probes, no more tackle boxes.

Again, the corollary to this protocol is NO ONE should EVER remove the probes from the machines. That is the main reason why they get lost or break.

Thanks, and please contact me with questions or issues.

Bret

Written by phil

January 21st, 2014 at 2:56 pm

Posted in Ultrasound

High Level Disinfection for transvaginal ultrasound probes

All faculty and residents- please note this important workflow change for high level disinfection of the transvaginal ultrasound probes:

After use of the Sonosite ultrasound probe for vaginal exam, the Charge Nurse (zone phone 78740) must be notified by the examiner to facilitate disinfection of the probe prior to the next exam.

The Charge Nurse will select an ED Technician (trained in the new process) who will remove the probe and cable from the machine for transport to the East Dirty Utility Room. There a Trophon machine that uses heated vapor and a concentrate of H2O2 will be used for disinfecting process. Only those who have completed a criterion checklist and competency under the supervision of persons designated can use the Trophon machine.

The ED Technician will then:
1. Disinfect the ultrasound probe using the Trophon machine per protocol
2. After disinfection, return the ultrasound probe to its proper location on the ultrasound machine
3. Wipe down the ENTIRE ultrasound machine (everything except the vaginal probe) using germicidal wipes

Please let me know if there are any questions or issues with this process. It has been mandated by Sinai’s Infection Control team; compliance, by definition, is mandatory.

Bret P. Nelson

Written by reuben

April 26th, 2012 at 5:49 am

Posted in Ultrasound

New Endocavitary Probe and Glidescope Flow

Dear Doctors and PAs,

We now have an easy, 7 minute process for high level disinfection of our vaginal probe for the ultrasound machine! Because the disinfection needs to be logged by a credentialed person, the techs will be in charge of this process.

We are also going to be taking our Glidescope blades to the sterile processing department (SPD) for sterilization until further notice.

I am forwarding Dwayne’s email below so you can see the workflow message that has been sent to the techs and nurses.
________________________________
From: Raymond, Dwayne
Sent: Friday, April 13, 2012 5:39 PM
To: Gardner, Keri; Baumlin, Kevin; Vella, Adam (MSSM); Fakih, Francine
Subject: High Level Disinfection Processes

There will be no change in practice until Monday (4/16) with another notice.

Process change #1, pending a few things on Monday:

After use of the Sonosite probe for vaginal exam, the Charge Nurse must be notified, by the examiner, to facilitate disinfection of the probe prior to next exam.

Thereafter, the Charge Nurse will select an ED Technician (trained in the new process) that will remove the probe and cable from the machine for transport to the East Dirty Utility Room. There a Trophon Machine that uses heated vapor and a concentrate of H2O2 will be used for disinfecting process.

Only those who have completed a criterion checklist and competency under the supervision of persons designated can use the machine.The process takes about 7 minutes.

Process change #2, pending a few things on Monday:

The Glidescope blade and stylet used in the AED will be sent to Sterile Processing Distribution for disinfection. We will be given another set in exchange. Note, the TAT for disinfection is 1 1/2 hours.

We will need to look into the use of disposable blades for the pediatric ED in particular. There isn’t presently a exchange set for pediatrics.

Thank you/Dwayne

Written by reuben

April 16th, 2012 at 5:19 pm

Posted in Airway,Ultrasound

Vaginal Probe Cleaning Process

After use of the Sonosite probe for vaginal exam, the Charge Nurse must be notified, by the examiner, to facilitate disinfection of the probe prior to next exam.

Thereafter, the Charge Nurse will select an ED Technician (trained in the new process) that will remove the probe and cable from the machine for transport to the East Dirty Utility Room. There a Trophon Machine that uses heated vapor and a concentrate of H2O2 will be used for disinfecting process.

Only those who have completed a criterion checklist and competency under the supervision of persons designated can use the machine.The process takes about 7 minutes.

– Dwayne Raymond

Written by phil

April 16th, 2012 at 3:32 pm

Posted in Ultrasound

REASON study

Sinai is part of the national REASON network (Real Time Emergency Assessment with Sonography: Outcomes Research Network).

The first data for this network now being collected is on patients in cardiac arrest.  We need to save 2 clips of cardiac (in)activity in these patients one during a pulse check and one after the code.  Preferably these would come 15 minutes apart.

Full instructions on saving clips on the M-Turbo and for the REASON study are available help.

Multimedia post with more information to come soon at the sinai ultrasound site.

Written by phil

August 12th, 2010 at 6:51 pm

Please log your ultrasound scans, and LOG OUT when done

Just wanted to clear up some confusion.

When you perform an ultrasound on a patient in the ED, you must save an image of the exam.

Press the YELLOW-labelled  “Start & End” button on any of the machines in the Mount Sinai ED. This allows you to enter the patient medical record number (under ID) as well as your IBEX initials (Under patient Last Name).

As you scan, images you save will then be saved properly with the proper identifying information.

When you are finished, press the YELLOW-labelled  “Start & End” button AGAIN, that ends the exam. Hence the name, “Start & End.” Just one button to remember, does two jobs.

Please follow the link below for an ILLUSTRATED tutorial on this:

http://sinaiem.us/tutorials/using-the-m-turbo

Why is this so important?

1. As soon as you end the exam, the images are wirelessly transmitted for electronic image archival to our department image database. If you don’t end the exam, the images will sit there, with no backup, prone to deletion or other data corruption.

2. If you don’t log out (end exam), the next person to use the machine will likely save THEIR images onto your login. The images will then show up as part of YOUR patient’s exam. We don’t need images of ascites., pregnancy, cardiac standstill, and AAA all logged in under the SAME PATIENT.

3. Do NOT leave the exam “Open” because you want to show the attending or someone else the study. ANY study on the machine can be viewed by pressing “Review” on the right side of the keyboard. All stored images currently on the machine can then be viewed. So if you want someone else to look at the images, you should still press “Start & End” after you scan.

Thanks again for your continued support. Stay tuned to SinaiEM.us and your email inbox for more exciting updates, including an upcoming cardiac resuscitation protocol!

Bret

Written by reuben

March 13th, 2010 at 4:34 pm

Posted in Ultrasound

MSSM Central Venous Catheterization Safety Policy

Ultrasonic guidance is now required per Medical Board policy for placement of all non-emergency central venous catheters in the internal jugular vein.  Attendings must be present at all critical events during central venous catheterization.  Chest radiography is insufficient to determine if a central venous catheter is in the venous circulation.  We must also measure pressure through the catheter (by manometry or pressure transducer), perform a blood gas analysis, or certain other methods.  Please read the policy in detail.  It is in effect immediately, and failure to comply is a serious matter.  Thank you for your efforts to increase patient safety.

CENTRAL VENOUS CATHETERIZATION SAFETY POLICY
This policy pertains to all elective central venous catheterizations. The policy does not apply during emergency circumstances.  Ultrasonic guidance of central venous catheterization reduces the incidence of inadvertent arterial cannulation. Ultrasonic vessel finder usage is required in all non-emergency internal jugular central venous catheterizations performed without fluoroscopy.
All elective central line insertions on patient floors will be performed by dedicated central line placement teams, such as the Surgical and Medical Intensive Care Unit Line Placement Services.
Appropriately privileged physicians who practice anesthesia, emergency medicine, critical care, and interventional procedures (interventional cardiologists, interventional radiologists, and nephrologists) may insert elective central lines in their procedural areas.  The Chief Medical Officer may identify other physicians that may receive privileges to insert elective central lines in specific procedural areas.
The attending physician must be present and visually supervise critical portions of the procedure, especially the confirmation of catheter placement within the central venous circulation.
A surgeon who has privileges to insert surgical central lines (e.g., Broviac catheters) in the operating rooms shall not place elective central lines outside of the operating room setting unless he/she is a member of a dedicated central line placement team or otherwise qualified as defined by the Chief of Service and the Chief Medical Officer.
Non-contrast radiographic examination will NOT be used to confirm the venous position of central venous catheters.  Radiologic examination is useful for determining the depth of insertion and the presence or absence of complications related to the central line placement, such as pneumothorax or hemothorax.
For all central venous lines, the techniques to be used for confirmation of venous placement include:
Observation of the intravascular pressure waveform using an electronic transducer and pressure tubing;
Determination of the of the intravascular pressure using sterile tubing as a venous manometer;
Analysis of the PO2 of a blood specimen drawn from the needle/catheter;
Using real-time fluoroscopic or echocardiographic confirmation of venous catheterization (e.g., visualizing the guide wire or catheter within the superior vena cava); or
Using a contrast study to opacify the venous structures.
For Insertion of Large-Bore Catheters and Introducers
To prevent inadvertent arterial cannulation with large-bore catheters (>5 French diameter or equivalent pediatric sizes), venous localization of the introducing needle or (angio) catheter must be confirmed by one or more of several techniques noted above prior to vessel dilation.  If technically unfeasible to conduct a confirmatory test with a short catheter or introducer needle prior to dilation, the recommendation is that a temporary catheter (<5 French) be placed to conduct one of the confirmatory methods.
In the event that no confirmatory test is conclusive, then the catheter must be removed.
The medical and nursing personnel present at the central line insertion must complete all applicable checklists, follow strict asepsis, and use all precautions currently required by the Central Line Associated Bloodstream Infection (CLABs) protocols of The Mount Sinai Hospital.  Nursing personnel will retain the authority to supervise and intervene to ensure that CLABs protocols are followed by the physicians and teams that are placing the central lines.  The current checklist for central line insertion is attached to this policy.
Ideally, central lines shall be removed no more than 7-10 days following insertion unless there are extenuating circumstances, which should be documented in the medical record.  Peripherally-inserted central catheter (PICC) lines are exempt from this requirement.  The primary service responsible for patient care shall monitor central lines for duration of insertion and signs of CLABs.  If the patient has a positive blood culture (as defined by CDC guidelines), the primary service will complete and forward a Root Cause Analysis (RCA) form to the Director of Epidemiology.  The current RCA form is attached to this policy.
The Materials Management service shall only distribute central line insertion materials and catheters to dedicated central line placement teams, and the procedural areas and patient care units where the physicians have privileges to insert central lines (see #2 above).  Sterile tubing to facilitate venous manometry shall be distributed with central line insertion materials  Central line insertion supplies shall be restricted to resuscitation carts and other emergency supply locations on patient floors.
NOTES ON LIMITATIONS OF THE TECHNIQUES TO PREVENT INADVERTENT ARTERIAL CANNULATION:
No one technique is guaranteed to be completely accurate in confirming venous location of a needle or catheter.
The following issues must be considered in interpreting these tests:
The “arterial-like” blood spurt and “arterial-looking” blood color are unreliable markers of the exact arterial location of a catheter and should not be used as confirmation of position, except in dire emergencies, such as CPR.
Manometric observation of a liquid column in the tubing connected to the catheter will provide a rough estimate of the venous or arterial nature of the intravascular pressure. However, manometric observation can be misleading in circumstances where the arterial pressure is low and the venous pressure is high.
Blood gas analysis is most effective when the sample from the central line is compared with a known arterial sample, or is <50 mm Hg in the presence of a high arterial saturation (>90%) as assessed using pulse oximetry.
Radiologic interpretation of a single planar image is not conclusive evidence of central venous catheterization due to the proximity of arterial and venous structures in the thorax.

CENTRAL VENOUS CATHETERIZATION SAFETY POLICY

This policy pertains to all elective central venous catheterizations. The policy does not apply during emergency circumstances.  Ultrasonic guidance of central venous catheterization reduces the incidence of inadvertent arterial cannulation. Ultrasonic vessel finder usage is required in all non-emergency internal jugular central venous catheterizations performed without fluoroscopy.

All elective central line insertions on patient floors will be performed by dedicated central line placement teams, such as the Surgical and Medical Intensive Care Unit Line Placement Services.

Appropriately privileged physicians who practice anesthesia, emergency medicine, critical care, and interventional procedures (interventional cardiologists, interventional radiologists, and nephrologists) may insert elective central lines in their procedural areas.  The Chief Medical Officer may identify other physicians that may receive privileges to insert elective central lines in specific procedural areas.

The attending physician must be present and visually supervise critical portions of the procedure, especially the confirmation of catheter placement within the central venous circulation.

A surgeon who has privileges to insert surgical central lines (e.g., Broviac catheters) in the operating rooms shall not place elective central lines outside of the operating room setting unless he/she is a member of a dedicated central line placement team or otherwise qualified as defined by the Chief of Service and the Chief Medical Officer.

Non-contrast radiographic examination will NOT be used to confirm the venous position of central venous catheters.  Radiologic examination is useful for determining the depth of insertion and the presence or absence of complications related to the central line placement, such as pneumothorax or hemothorax.

For all central venous lines, the techniques to be used for confirmation of venous placement include:

Observation of the intravascular pressure waveform using an electronic transducer and pressure tubing;

Determination of the of the intravascular pressure using sterile tubing as a venous manometer;

Analysis of the PO2 of a blood specimen drawn from the needle/catheter;

Using real-time fluoroscopic or echocardiographic confirmation of venous catheterization (e.g., visualizing the guide wire or catheter within the superior vena cava); or

Using a contrast study to opacify the venous structures.

For Insertion of Large-Bore Catheters and Introducers

To prevent inadvertent arterial cannulation with large-bore catheters (>5 French diameter or equivalent pediatric sizes), venous localization of the introducing needle or (angio) catheter must be confirmed by one or more of several techniques noted above prior to vessel dilation.  If technically unfeasible to conduct a confirmatory test with a short catheter or introducer needle prior to dilation, the recommendation is that a temporary catheter (<5 French) be placed to conduct one of the confirmatory methods.

In the event that no confirmatory test is conclusive, then the catheter must be removed.

The medical and nursing personnel present at the central line insertion must complete all applicable checklists, follow strict asepsis, and use all precautions currently required by the Central Line Associated Bloodstream Infection (CLABs) protocols of The Mount Sinai Hospital.  Nursing personnel will retain the authority to supervise and intervene to ensure that CLABs protocols are followed by the physicians and teams that are placing the central lines.  The current checklist for central line insertion is attached to this policy.

Ideally, central lines shall be removed no more than 7-10 days following insertion unless there are extenuating circumstances, which should be documented in the medical record.  Peripherally-inserted central catheter (PICC) lines are exempt from this requirement.  The primary service responsible for patient care shall monitor central lines for duration of insertion and signs of CLABs.  If the patient has a positive blood culture (as defined by CDC guidelines), the primary service will complete and forward a Root Cause Analysis (RCA) form to the Director of Epidemiology.  The current RCA form is attached to this policy.

The Materials Management service shall only distribute central line insertion materials and catheters to dedicated central line placement teams, and the procedural areas and patient care units where the physicians have privileges to insert central lines (see #2 above).  Sterile tubing to facilitate venous manometry shall be distributed with central line insertion materials  Central line insertion supplies shall be restricted to resuscitation carts and other emergency supply locations on patient floors.

NOTES ON LIMITATIONS OF THE TECHNIQUES TO PREVENT INADVERTENT ARTERIAL CANNULATION:

No one technique is guaranteed to be completely accurate in confirming venous location of a needle or catheter.

The following issues must be considered in interpreting these tests:

The “arterial-like” blood spurt and “arterial-looking” blood color are unreliable markers of the exact arterial location of a catheter and should not be used as confirmation of position, except in dire emergencies, such as CPR.

Manometric observation of a liquid column in the tubing connected to the catheter will provide a rough estimate of the venous or arterial nature of the intravascular pressure. However, manometric observation can be misleading in circumstances where the arterial pressure is low and the venous pressure is high.

Blood gas analysis is most effective when the sample from the central line is compared with a known arterial sample, or is <50 mm Hg in the presence of a high arterial saturation (>90%) as assessed using pulse oximetry.

Radiologic interpretation of a single planar image is not conclusive evidence of central venous catheterization due to the proximity of arterial and venous structures in the thorax.

Written by reuben

March 12th, 2010 at 5:00 pm

Ultrasound machine tips

1. You MUST save images when using the ultrasound machine, and the attending must see the images if they are used to determine patient care. We have had several cases recently where patients were subjected to additional scans because the resident didn’t save images of their initial scan. This causes delays in patient care, decreased patient satisfaction, and increases costs.

2. You MUST login in (START/END key), then log out (START/END key again) when you are done. We have may scans that were saved under the wrong patient name because someone didn’t log out.

Thank you for your help, and visit www.SinaiEM.us for tutorials on how to scan, how to use the machine, etc.

Please email me with any questions.

Bret

Written by reuben

November 12th, 2009 at 7:09 pm

Posted in Ultrasound

Ultrasound Clarifications

Just to clarify some misconceptions:

1. Where are the ultrasound machines?

The machine labeled “Resus” should be kept near Resus, plugged in
The machine labeled “South 13″ should be kept in South 13, plugged in
The same pattern is repeated for the machines labeled, “Peds 4″ and “South 9″
Try to leave the vessel finder (the “S-Cath” machine) near Resus, or at least in some obvious, open location. When it is used in the back of a patient room for an IV and left there, the next user will have difficulty finding it.

2. Which gel should be used for the ultrasound machines?

“Ultrasound Gel” is for ultrasounds. It is optimized to conduct sound waves

“Electrode Gel” is for electrodes (like the defibrillator paddles). It is optimized to conduct electricity. When used with ultrasound it yields worse images, is hard to clean off the probes and patients, and often implies that somewhere there is a defibrillator without gel.

3. Who left the machine dirty?

We are actively investigating the “two guys” who leave the probes covered in gunk, unplug the machines, and hide them in the utility rooms while the rest of the ED staff are minding their own business. Until these perpetrators are apprehended, please be sure to leave the machine ready for the next person to use:

-Clean the probes with TranSeptic spray before and after each use
-Leave the machines in their proper location, plugged in
-Do not leave garbage, especially medical waste and sharps, on the machines

Thank you for your support,

Bret

Written by reuben

October 13th, 2009 at 9:47 pm

Posted in Ultrasound

SonoSite S-Cath

I am pleased to announce we are going “live” with our new ultrasound machine, the SonoSite S-Cath. It is the grey flatscreen monitor machine with a vascular probe attached to it.

The machine should be used to place difficult peripheral IV lines, and ALL central lines should be placed under ultrasound guidance.

There is a very brief tutorial on using the machine at:
http://sinaiem.us/?page_id=170

Basically, the ON button is on the top left of the machine. There are two knobs: they control Depth and Gain. There are no other controls to worry about.

A few more things to keep in mind:

1. Clean the probe
This is a medical device and according to OSHA regulations and common courtesy, it cannot be left bloodied or gooped up. The probe goes in the probe holder to the right of the machine.

2. Return the machine to the Resus area
The glidescope and ultrasound machine get plugged in behind the MD workstation, next to the secure document receptacle.

3. Plug the machine in as much as possible
When the battery is low, it will shut down while you are trying to place a central line.

4. Use extra-long IV catheters for deeper veins
They are located in the Resus area storage bins (alcove under blanket warmer) and in the ED storeroom (on your left just behind the door).

Please email me with any questions, and thank you in advance for taking good care of the machine.

Bret

Written by phil

February 18th, 2009 at 1:15 pm

Posted in Ultrasound

EM Ultrasound

Here are answers to seven frequently asked questions about the ultrasound program. Further details, tutorials on ultrasound use, and lots of pictures can be found at: www.SinaiEM.us

1. Where is the ultrasound machine?

  1. a. There should be an ultrasound machine in the following locations:

    • i. RESUS area (in alcove to the right of Resus Printer, beneath the blue and grey Ultrasound Poster)
    • ii. Gyn rooms 9 or 13
    • iii. Peds room 4
    • <

  2. b. Often machines find themselves in other areas, including patient rooms, hallways, or Urgent Care

2. Do I need to save images?a. YES
b. EVERY TIME YOU USE THE MACHINE

3. How do I save images? (details with pictures at http://sinaiem.us/?page_id=162 )a. Press “Patient” button on machine
b. Enter YOUR IBEX initials (ie. ABN or EBN) under the Patients’ Last Name
c. Enter the patient’s MR# under ID
d. Press “Done” to begin scanning- you should now see your IBEX initials and the Patient MR# on the top of the screen
e. FREEZE (big blue button) the desired image, and press SAVE
f. SAVE as many images as you like- at least two views of any organ of interest
g. When you are finished, press the triangle (END) key to log off

4. How do I clean the machine?
a. Use the TranSeptic spray- spray liberally, wipe clean

5. What do I do if the probes are dirty?

a. NEVER use a dirty probe for patient care.

b. Clean probes with TranSeptic Spray before using them in patient care, and before returning the machine to its normal location

6. How many ultrasounds do I need to become credentialed?

a. Faculty need 25 (twenty-five) documented ultrasounds (images and interpretations) in a particular indication (ie. Cardiac, pelvic) to become credentialed

b. Residents need the same number, though they cannot be ‘credentialed’ from a hospital perspective while in training

7. Where are the extra-long needles, useful for placing deep peripheral lines with ultrasound guidance?

  1. In the Red Suture Cart located near the ambulance entrance in the North Zone. Top Drawer.
  2. 1.88 inch, 18-guage catheters and 3.25 inch, 16-guage catheters are available there in addition to the standard angiocath sizes.

Thank you for your help, and please email Bret Nelson with any questions.

Written by phil

August 15th, 2008 at 11:58 pm

Posted in Ultrasound

ACEP Focuson Ultrasound

From Dr. Nelson:

There are nice walkthroughs of pelvic ultrasound and ultrasound for procedure guidance (with pictures!) at: www.acep.org/focuson. You can even get CME credit.

There are others if you’re interested (on peritonsillar abscess, lumbar puncture, etc.), but I recommend looking at these two:

  • Focus On: Ultrasound Imaging in First Trimester Pregnancy July 2008
  • Focus On: Ultrasound-Guided Central Venous Access of the Internal Jugular Vein November 2007

Written by phil

August 15th, 2008 at 2:12 pm

Posted in Ultrasound