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Fairbanks Memorial Hospital (Fairbanks, Alaska)

CSI Summary

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CSI Presentation

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CSI Toolkit

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Project Topic

Procedural preparedness

Hospital Unit


CSI Participants

Nancy Griffith, BSRT, (R), (M), (CT), (MR), (QM)
Tamara Jones, RT, (R), (QM)
Amber Lorenzana, BSN, RN
Kelly Martin, BSN, RN
Diana Patterson, RT, (R)

Project Goals/Objectives

  1. To increase to 95% the number of procedures that have all required pre-data documentation the day before the procedure

Project Outcomes

  1. Increased receiving pre-data required documentation on the day of the scheduled procedures from 37% to 96.7%
  2. Increased our same day add-on availability and inpatient procedures overall during the later quarters of our project, increasing the number of total procedures we were able to perform in Radiology

Project Overview

Patient history and physical is an important and vital components in performing Radiology procedures. Mistakes that could cause harm to the patient during the procedure – as a result of the procedure itself or moderate sedation – can be largely avoided if a proper history, physical and laboratory results are available to the Radiology team.

Many patients have complicated medical histories that could cause issues during sedation or procedures. For instance, many patient on anticoagulation therapies require biopsy, but in order to perform this procedure safely, the nurse must ensure the patient has optimal coagulation. Without laboratory results, history and physicals, the physician and nurse will not be prepared should problems arise during the procedure. This poses an unnecessary risk for patients. Our CSI team chose to focus on this issue, hoping to implement changes that would help alleviate some of those risks.

Achieving our goal of having 95% of all procedures “good to go” by 2 p.m. the day before the scheduled procedure required a change in internal processes and development of external processes. We standardized documentation guidelines and educated outpatient ordering providers. Our team created a documentation reminder that is faxed up to seven days prior to the scheduled procedure, making providers and staff aware of missing documentation. The reminder includes a notification that the procedure will be rescheduled for missing documentation.

Alaska presents geographical challenges for some patients, so we have specified that a plan for lab values is acceptable if the patient is not local or lives in a place where labs are difficult to obtain. As part of our project, same-day order guidelines were established and shared with the outpatient ordering providers.

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The materials associated with this AACN Clinical Scene Investigator (CSI) Academy project are the property of the participating hospital noted above, not AACN. Requests to use content contained in the CSI team’s summary, presentation or toolkit should be directed to the hospital. We suggest reaching out to the hospital’s Communications, Marketing or Nursing Education department for assistance.

The AACN CSI Academy program supports change projects based on quality improvement methods. Although CSI teams seek to ensure linkage between their project and clinical/fiscal outcomes, data cannot be solely attributed to the project and are estimations of impact.