Fine needle aspiration has become an integral part of endoscopic procedures. It's safe, effective and less invasive than other methods for obtaining tissue samples. Here's a step-by-step guide for the GI nurse or technician assisting the physician in preparing and obtaining fine needle aspiration.

Step 1. Assemble the following equipment:

• FNA needle; 19g, 22g and 25g
• normal saline
• two 10cc syringes
• sterile basin
• tissue-marking pencil
• fixative
• light source
• cardboard slide holders
• slide container with 95% alcohol
• cell block container

Step 2. Before the procedure, check the FNA needle lock and ensure the needle moves freely in and out of the sheath. Prepare the vacuum syringe to proper suction depending on the type of lesion and physician preference and prepare the specimen slides with patient identifiers. Have adequate lighting available. Per institutional protocol, notify pathology.

Step 3. The physician identifies the lesion using ultrasound. Assist by holding the scope steady and removing the biopsy channel cap. Pass the FNA needle through the biopsy channel and fasten in place. The physician identifies needle placement in the lesion. Remove the FNA needle stylet and place the vacuum syringe on the needle. Open the stopcock, creating suction to aspirate the cells. After specimen is obtained, the physician closes the stopcock and withdraws the needle into the sheath. Remove the syringe assembly from the scope.

Step 4. Position the FNA needle above the slide, bevel down, without touching the slide's surface. Reinsert the FNA needle stylet and perform repeated short passes to expel the maximum amount of aspirate onto the slide. Place aspirate close to the frosted end of the slide. Remove the stylet and place a 10ml air-filled leur-lock syringe on the FNA needle. Expel remaining aspirate onto slides by forcing air out of the syringe. Place a clean slide on top of the aspirate (frosted sides together). Gently pull the slides apart to create a flame-shaped smear on each side. Place one slide in the 95% alcohol container. Let the second slide air dry and place it in a cardboard slide holder.

Step 5. To prevent clotting of any remaining aspirate on the FNA needle, perform a cell block. Fill a 10ml syringe with normal saline. Flush the FNA needle into the cell block bottle until the saline runs clear. Add fixative to equal the amount of saline in the cell block bottle. Quickly complete slide preparation to prevent clotting of aspirate.

Step 6. To secure additional specimens from the same biopsy site, clean the stylet with saline, reintroduce it into the FNA needle and hand it to the physician for another pass. When taking additional specimens from a different biopsy site, a new FNA needle and slide setup is needed to avoid cross contamination. Label all specimens and complete the laboratory requisition according to your facility's policy.

JoAnn Fuller, RN, CGRN
Cindy Tiemann, BA, BSN, RN, CGRN
Certified Gastroenterology Nurses
Wentworth Douglas Hospital
Dover, N.H.
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How Smart Are Your Monitor's Alarms?
Your monitor's alarm system is the first signal of possible trouble. The American Society of Anesthesiologists' required alerts include low oxygen concentration during general anesthesia, variable pitch pulse tone and low-threshold alarm for pulse oximetry, an end-tidal CO2 alarm when capnography is used during intubation and a disconnection alarm when a breathing system component disconnects.

To avoid alerts that staff may ignore because they sound too loud and too often, consider monitors with programmable "smart" alarms, letting you set the sounding parameters. Most monitors today also have soft and hard alarms to provide audible cues to staff that allow for appropriate responses to each beep and buzz. Soft alarms alert staff to changes in the patient's condition that may require action - a slight drop in air pressure, for example. Hard alarms signal critical event signals that notify staff of changes in the patient's state that demand immediate attention - like a ventilator disconnect.

Alarms, even the loudest, may get lost in the ambient noise of the OR and PACU. That's because the audibility of alarms is dependent on both the tone and amplitude of the sound waves it generates. High-frequency alarms may be inaudible to anesthesia providers and clinical staff who lose their ability to hear high frequency tones as they age - not an unlikely problem based on the trends in healthcare workforce demographics. So trial monitors before buying. Set the alarms to determine if they're audible in all clinical areas during the ebbs and flows of the surgical schedule.

Kevin B. Gerold, DO, JD, MA(Ed)
Assistant Professor of Anesthesiology
Johns Hopkins School of Medicine, Baltimore, Md.
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Customize Your Schedule Based on Physician Preferences
Like all surgeons, our GI docs differ greatly in how they perform procedures. That's understandable, but it can wreak havoc on our scheduling. We developed, with the help of our GI docs, individualized scheduling templates for each. On the templates, physicians identify the number of patients they can complete in a half-day or full-day block (which corresponds to our schedule) and the amount of time they'll need for specific schedules.

Some doctors choose a half-day with 30-minute slots, nine procedures and one room, swinging between them with two sedators. Others choose full-day blocks divided into 20-minute slots for 23 procedures and "wave scheduling," in which patients arrive two at a time, keeping two procedure rooms filled as the doctor swings between the first patient ready and the second. For either method, we assign sedators, nurses and techs to a physician's team for the day and the day's staffing is adjusted to fit the templates, which are built into our scheduling system.

The template model of scheduling and team approach to staffing offer benefits on several fronts. We've seen increased patient volume and decreased physician downtime since each docs is working at a pace that's comfortable for him. The team approach ensures continuity of patient care and improves handoff communication since each nurse is interacting with only one physician. Additionally, we've seen our discharge times fall when teams work together to meet patient needs in a timely manner.

Denise Ertl, RN, CGRN
Director
Aspirus GI Center
Wausau, Wisc.
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Training's More Fun When You Make a Game of It
Let's face it, staff hate training sessions. As I searched for a new way to present information, my husband came up with the idea of using a gameshow format. That inspired me to create "Policy Jeopardy." I made a board with 30 square slots that hold questions I wrote out on index cards. I split the questions into six categories, including patient safety, disaster codes, sterile processing, perioperative procedures and PACU. I based most of the questions on the rules I most often saw broken or the issues that showed up on incident reports. I also included questions on issues that I wanted to reinforce, such as OSHA regulations. I designed the board so the staffers could see the question they picked but not the answer, which was on a lower part of the card. I also included the source for the answer in case anyone wanted to find out more about that rule. After assigning five, 10, 15, 20 or 25 points to each question based on its level of difficulty, I was ready to assume the role of gameshow host.

I split the staff into two competing teams, each containing RNs, CRNAs and administrators. They had to work together to pick the questions and earn points. To make things more interesting, I included "Daily Doubles" and attached candy to some questions. The winning team's members also got gift cards to Wal-Mart. We've only played "Policy Jeopardy" once, but the staff loved it. They said that session was the most fun they've ever had while learning.

Wendy Cherveny, RN, OND
Nurse Manager
Cityview Surgery Center
Fort Worth, Texas
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