Neuro-Intra-Operative Monitoring (IOM): Meeting increasing institutional needs, while maintaining quality. (& the “Unexpected” benefits of service development) Renata Glowka, R EEG T. R PSG T Michael JM Raffin, Ph.D. Jagruti Patel, CNIM, R EEG T Micheal Macken, MD Gregory Gruener, MD, MBA

Compelling Factors for an “Intervention”  Increasing caseload demands and case complexity  Increasing duration of IOM time/case  Limitations in technologist availability & capabilities  Limitations in technical support  Lack of an integrated intradepartmental strategy  Need for new protocol (& physician) development  New surgical and program monitoring needs

Description of Our Project & Aims  Reduce usage of outside agencies by technologist development Maintain Loyola’s standards of excellence through active monitoring of service and feedback from “customers” 4-step career ladder and cross-training process developed for technologists as well as their professional support to encourage certification Collaboration with the Department of Audiology to develop new skills of their Audiologists that allow their use in some IOM roles  Meet increased volume and availability demands by cross-training of technologists and monitoring of needs/procedures to allow their proper assignment  Meet increased technological needs through strategic equipment purchasing, infrastructure support and wireless intraoperative monitoring transmission to allow “real-time” physician availability for monitoring  Develop new IOM protocols and procedures through faculty and technologist development  Increase institutional satisfaction with IOM services as their needs are met

Reliance on Outside Agencies  Solutions that were successfully implemented Inter-disciplinary involvement in the provision of services Inter-disciplinary involvement in the provision of services Technologist recruitment and development Technologist recruitment and development Expansion of technologies and personnel skill mix Expansion of technologies and personnel skill mix Maintain compliance with professional standards of careMaintain compliance with professional standards of care Successfully integrate new technologies and capabilitiesSuccessfully integrate new technologies and capabilities Development of new services Development of new services Transcranial cortical motor evoked potentialsTranscranial cortical motor evoked potentials CorticographyCorticography Functional cortical mappingFunctional cortical mapping Intra-cranial epilepsy monitoringIntra-cranial epilepsy monitoring

Our results - “New” Intra-Operative Monitoring Technologists Left to right: Denise Rys, Jagruti Patel, R. EEG T., CNIM, Gazenfer Sherazeen, R. EEG T., CNIM, Renato Cunanan, R. EEG T.

Our results - Integration of Audiologists Left to right: Kathleen E. Schore, MS, CCC-A, F-AAA; Ying Sun, MS, CCC-A, F-AAA.

Our Results - Agency Reduction  Costs: Agency: $1,720/case, LUHS: $360/case Agency: $1,720/case, LUHS: $360/case Per-case cost reduction = 79% Per-case cost reduction = 79% FY2006 cost savings = $30,000 FY2006 cost savings = $30,000  Agency reliance: Reduced from 5% to 0.5% of cases. Reduced from 5% to 0.5% of cases.

IOM service needs - #1: Increasing IOM cases

IOM service needs - #2: Increasing monitoring hours

IOM service needs - #3: Caseload variability

All of these IOM service needs were met by “matching” them to IOM staff availability and cross-coverage

Our Results - Our “Customers”….

... and their Satisfaction….

…as well as the comments we received from our Surgeons Direct Quotes Staff are very cooperative and helpful Excellent service. Dr. Macken works well with service. This service is very accommodating. Good job. Suggestions for service improvement: None. Excellent staff. Suggestions for service improvement: None. Audiology provides an excellent service to our Dept. The biggest problem we still face is the occasional background artifact rendering effective monitoring useless. Monitoring team and bioengineering employees still have no answers. Must solve this issue! Great service. Looking forward to doing collaborative research. Nice team. Technicians are very good and interact well with both the anesthesia teams and surgeons. Good at timely setup with minimal delays. It may be worthwhile to expand the service by one more individual since I do see locums neurophysiology techs here on occasion. I believe your services are all very good.

“Unexpected” benefits of IOM service development  Development of a reliable IOM team that has successfully integrated with the surgical teams and surgeons  Increased attractiveness of LUHS to support new surgical faculty who are dependent upon IOM  Increased attractiveness of LUHS to aid future technical staff recruitment and retention  Increasing ability to accommodate emergency surgical cases as well as complicated and extended surgeries  Ability to explore and initiate new synergies with other departments (Audiology/Otolaryngology) as well as support new program development or capability (CV surgery and anesthesiology)  Increased Hospital Administration’s direct involvement and support  Establishing Level 4 Epilepsy Center

Opportunities for Continued Development  Continued daily monitoring of OR schedule to ensure timely response to the present demands for services.  Design and implementation of studies for post- surgical outcomes.  Support for basic and applied research opportunities.  Expansion of available resources to meet increasing as well as new demands.