1. Access the list of biopsy requests on Epic.

FOR THE PROTOCOL WORKLIST:

• In Epic, click on the protocol worklist tab 

• Click on ‘Views’ (top left)

• Click on Settings (top of list)

• Select MGH IR MSK Planning Queue under the PUBLIC folders (and delete any private lists you might have listed under your name)

• Set as ‘My default’ (bottom left)

• Click Run

2. Review the biopsy with your staff ASAP. If the biopsies are not reviewed and approved, they cannot be scheduled. Please note which staff you discussed the biopsy with. (Special cases - discuss all osteoid osteoma ablations with Ambrose or Jad; discuss all other ablations with AJH; discuss sclerotherapies with CYC).

3. One of three things could happen:

a. Decline. If you decide to decline the biopsy, you should contact the referring physician, either by phone (if inpatient) or by email (if outpatient) to explain the reason for declining the biopsy. You should also write down the reason for declining the procedure under "comments", and put your initials (fellow + attending) before finalizing it.

b. Re-route to another service. Sometimes the biopsy should go to GI interventional, breast, or chest.  General IR (listed on Epic as Abdominal IR Planning Queue) is a common overlap because some cases are ordered as "soft tissue mass" and end up in our queue. Examples of cases that should be re-routed to GI include retroperitoneal masses, most cases of cervical/axillary/inguinal lymphadenopathy, and any aspiration cases that require drainage catheter placement. 

c. Put on hold. Sometimes additional information or imaging is needed prior to evaluating the biopsy request. You should make this clear under Order Notes (i.e. what you are waiting for).

d. Accept. If you accept a biopsy, you need to:

i. Make a decision about conscious sedation. 

1. Conscious sedation is generally performed by our departments’ nurse anesthetists. As a general principle, soft tissue biopsies do not require conscious sedation. Bone biopsies can be done under local anesthesia only as well, but many may need conscious sedation, especially for discitis/osteomyelitis. The patient’s age and level of anxiety also play roles in this decision. Consult the biopsy staff and the ordering physician about this information. (Additional side note – it is easier to ask for conscious sedation ahead of time and cancel later than to try to add it on at the time of the biopsy. But it is still better to clarify the situation ahead of time).

2. If you decide to use conscious sedation, remember the patient has to be NPO 8 hours prior to the procedure.

3. Some patients may require anesthesia. If it is an OUTPATIENT biopsy or other procedure (such as radiofrequency ablation), Michelle will usually take care of it. If it is an INPATIENT add-on, please see orientations below how to request it.

4. If pediatric patients need conscious sedation, you will also need to get anesthesia involved (these are usually done as an outpatient, so ask Michelle for help with it). If it is an inpatient, then you may need to coordinate with IR resources similar to adults (see below).

ii. Log the relevant details in Epic (there is a "comments" section)

a. Suggested lesion approach – this is a combination of ordering physician preference, imaging findings, and staff preference (look carefully for potential obstacles, such as nerves, blood vessels). Make sure you check with orthopedic oncology if they have any approach that will affect their surgery (this is generally for chordoma and sarcoma, but it’s a good practice to check just in case).

b. Suggested needle type (although the staff performing the biopsy may have their own preferences).

c. If there is more than one lesion, which lesion to biopsy.

d. If special tests are required on the pathology specimen, what they are and if any particular person needs to be called to collect the sample. 

e. If the patient is not consentable, who to contact to obtain that consent.

f. If the patient is on anticoagulation, that the patient or the team has been informed to hold the medication.

g. If the patient needs blood products (whole blood, platelets, FFP), special medications, CPAP, lab tests on the day of the procedure.

h. If special medications are needed for the procedure – what type, dose, and route of administration.

5. Communication between you and your colleagues is of UTMOST important. A verbal sign-off or an email can often smooth things out and fill in the cracks – and it’s always better to err on the side of a sign-off! Also, someone should be taking notes during Tuesday AM conference - because often important biopsy details come up during that time.

iii. Please log the initials of the STAFF who has approved the procedure in the comments section of the biopsy approval panel. If the case was discussed in Tuesday morning conference, you can also document this information there.

iv. Keep requests in the protocol list (do not Finalize it) until nursing review is done. This is per request of the IR nursing department.

SPECIAL CASES:

• US or RF procedures, including botox injections, which end up on the MSK IR request list from time to time

  • Michelle and Donna can see these. So, your choice. Approve or decline. In either case, Michelle and Donna will work on scheduling or canceling them and can still see them no matter what you do (yes, this is another Epic glitch).

• Ablations

  • Email Ambrose/Jad/Connie about them. Usually they already know about them and the approval is just a procedural step.

• Sclerotherapy

  • Ask CYC, see special page

• Inpatient anesthesia case: see below

• To get an add-on inpatient anesthesia case scheduled you have to coordinate it with two services: Anesthesia and General IR (which organizes the schedule for anesthesia cases, usually done in the Gray CT) 

• For Anesthesia, you need to place an order in Epic (see images below)

  • If the patient is somehow already scheduled, you can access their chart through the Snapboard, otherwise you can open an "Orders Only" encounter, go to "Prep for Procedure" tab

  • Search for the order: "Case request operating room"

  • Fill out the required fields and sign it

  • The case is now officially in the Anesthesia waitlist

• Now you have to contact the General IR resources (usually Brian Oakes, pager 20271, or Chris Rodrigues, pager 12415) to let them know you have placed an anesthesia request and they will contact you when the case is scheduled. Always keep Michelle in the loop as well.

IMPORTANT:

• It is very unlikely that an anesthesia case will be done on the same day of the request, so it is good practice to give the care team a heads up (so  they don't keep the patient NPO waiting for the procedure)

• Check back with IR (Brian Oakes or Chris Rodriguez) on a daily basis in case they don't find you a slot for the next day or so. For some reason, our requests may fall through the cracks and if you don't check frequently, it may not get scheduled.

• Sometimes they need you to update the "case request" order in Epic because of some change in the Anesthesia waitlist (they will let you know if that is the case)

• On the day of the procedure it will be like any other CT case, except that you will need to meet the patient when Anesthesia is getting consent to get your own consent for the procedure (usually done in the CT room), and you don't need to fill out a "pre-sedation evaluation" in Epic (post procedure orders for discharge are still needed though)