Protecting Patients 3/5/2014. Educating and Engaging your Staff in Radiation Safety

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Scott Woods
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1 Educating and Engaging your Staff in Radiation Safety Robert Vincent MD;CM FACC Professor of Pediatrics Emory University School of Medicine Ralf Holzer MD Associate Professor of Pediatrics Ohio State University College of Medicine Protecting Patients Institute of Medicine: Statement on Quality of Care: National Roundtable on Health Care Quality The Urgent Need to Improve Health Care Quality. Jan 1, 1998 The participants concluded that the quality of health care can be precisely defined and measured with a degree of scientific accuracy comparable with that of most measures used in clinical medicine. Serious and widespread problems exist throughout American medicine. These problems, which may be classified as underuse, overuse, or misuse, occur in small and large communities alike, in all parts of the country, and with approximately equal frequency in managed care and fee-for-service systems of care. Very large numbers of Americans are harmed as a direct result. Quality of care is the problem, not managed care. Current efforts to improve will not succeed unless we undertake a major, systematic effort to overhaul how we deliver health care services, educate and train clinicians, and assess and improve quality - See more at: Roundtable-on-Health-Care-Quality--The-Urgent-Need-to-Improve-Health- Care-Quality.aspx#sthash.erOsH3Vv.dpuf WE HURT PATIENTS! 1

2 How Safe Is Healthcare? Dangerous > 1 / 1,000 Ultra Safe < 1 / 100K 100,000 Total lives lost per year 10,000 1, of ~ ,000 10, K 1M 10M Number of encounters for each fatality From: Highly Reliable Healthcare the science of safety. Healthcare Improvement Performance, LLC. OCHSPS National Children's Network March 15, Complementary Strategies Fall Prevention Medication Errors Central Line Infections Hand Hygiene Culture of Patient Safety Radiation Safety The next frontier Unlike other forms of injury, the injury may not be apparent at the time, during the admission or for months or years afterwards. 2

3 What is Your Culture? Like all of the other programs to reduce harm and improve quality, Radiation Safety is a team exercise Every member of the team needs to be responsible and accountable. Everyone needs to speak up and others need to be responsive and accepting of suggestions/criticisms. Radiation Biology Deterministic effects Those in which the number of cells lost in an organ or tissue is so great that there is a loss of tissue function, such as skin erythema and ulceration Appear to have a threshold Stochastic effects Occur if an irradiated cell is modified rather than killed and then goes on to reproduce Do not appear to have a threshold and the probability of the effect occurring is related to the radiation dose Deterministic Effects of Radiation Exposure to Skin Chambers C, Fetterly K, Holzer R, Paul Lin P, Blankenship JC, Balter S, Laskey W. Radiation Safety Program for the Cardiac Catheterization Laboratory. CCI 2011; 77:

Quantifying the Stochastic Risk Cancer after exposure to low level radiation < 100 msv (BEIR VII report 2006) Excess cancer cases ~1% Excess cancer related death ~0.

4 Quantifying the Stochastic Risk Cancer after exposure to low level radiation < 100 msv (BEIR VII report 2006) Excess cancer cases ~1% Excess cancer related death ~0.5% Lifetime attributable risk of cancer mortality after single cardiac catheterization in pediatric patients (Beel L et al, Circulation, 2009): Estimate by linear no-threshold model: 1 in 1,000 Estimate using biological data (γ-h2ax foci): 4 in 1,000 Stochastic Radiation Effect: The Pediatric Problem Children are at potentially greater risk of stochastic effects due to: Greater radiation sensitivity of their tissue compared with adults More remaining years of life during which radiationinduced malignancies may develop Often multiple radiological procedures over lifetime with cumulative exposure not being tracked or monitored 4

Date 4 year male with PA VSD MAPCAS - The Pediatric Problem - Type of cath Fluoro time Cum air KERMA 2007-Dec Diagnostic 22 min 229 mgy 2008-Jun Diagnostic 35 min 785 mgy 2008-Jun Hybrid PA Rehab 13

5 Date 4 year male with PA VSD MAPCAS - The Pediatric Problem - Type of cath Fluoro time Cum air KERMA 2007-Dec Diagnostic 22 min 229 mgy 2008-Jun Diagnostic 35 min 785 mgy 2008-Jun Hybrid PA Rehab 13 min 290 mgy 2008-Aug PA Rehab 70 min 2,148 mgy 2008-Dec PA Rehab 123 min 2,709 mgy 2009-May PA Rehab 102 min 3,788 mgy 2009-Dec PA Rehab 77 min 1,012 mgy 2011-Mar PA Rehab 129 min 1,965 mgy 2011-Nov Exit Angio 3 min 148 mgy Additional X-ray exposure: 84* CXR, 16* AXR, 4* CT chest, 4* CT brain, 2* NJ tube placement, 1* cyturethrogram Setting A QI Goal: Reduction in Patient Dose Reduction in median dose by 25% over a 12 month period Increasing awareness as the key ingredient to quality improvement efforts After the introduction of a radiation threshold monitoring and notification policy, there was a statistically significant decrease in radiation dose CCI

6 Staff Education Establish a Cath Lab Radiation Safety Committee Educate Cath Lab staff, fellows and physicians on risks of radiation and techniques to minimize their and their patients exposure Learn advantages and disadvantages of different measures of radiation exposure. Staff Participation Should Radiation parameters be part of time out? Shielding Frame Rates Cameras and coning Monitoring radiation indices Notifying physicians at set radiation points - What YOU Need to Do! Follow general radiation dose reduction principles ALARA - As Low As Reasonable Achievable Refers to all aspects of radiation safety Using the lowest possible dose while completing procedure safely Recognize the importance of time, shielding, and distance Follow general published dose reduction guidelines Radiation Safety Program for the Cardiac Catheterization Laboratory (Chambers et al, CCI, 2011) Page 6 refers to specific procedural techniques that can be used to reduce radiation exposure Use available online resources Step Lightly (Image Gently) Introduced by the Alliance for Radiation Safety in Pediatric Imaging Downloadable checklist for dose reduction Downloadable outline of dose reduction and quality maintenance steps to take in the department 6

7 Some measures have the ability to yield large dose reductions possible examples (among many) that could be implemented: Reduce the standard frame rate for fluoroscopy and digital acquisition Basic frame rate settings should be sufficiently low so that operators have to opt out if higher frame rates are required for specific cases, rather than opting in to reduce the frame rates Use fluoro record whenever possible (new imaging equipment often provides excellent quality) Encourage use of equipment (shields) and radiation drapes (to reduce effect of radiation scatter) Regular review and adjust individual settings for different patient sizes (together with physicist) Specific Aim Median cath lab exposure per case will be 75% of the median dose achieved during the preceding year. Radiation Safety Aim : Reduction in patient dose - Goals: Reduction in radiation dose (QI examples) Key Drivers Equipment, Process & Operator Physician Staff Interventions Increased use of collimation when appropriate Reduce magnification unless absolutely needed Decrease frame rate to 10fps when possible (based on pt wt) Increase use of fluoroscopy recording instead of digital acquisition Use of Live Zoom rather than using Radiological Zoom (8 with live zoom rather than 7 ) Enable system alerts for staff and physicians Last revised: 9/28/11 - Look back and follow your results (QI Example) - Increased use of Fluoro Record Fluoro frame rates from 30 to 15 fps Acquisition frame rates from 30 to 15 fps 7

Are you just involved or committed During a long hard case that was not going well, in an institution where the staff and physicians had an excellent working relationship and mutual respect, the

8 Are you just involved or committed During a long hard case that was not going well, in an institution where the staff and physicians had an excellent working relationship and mutual respect, the cardiologist was shown this note from the staff Your village just called. Their idiot is missing!!! The Challenges 1. Are you willing to change? 2. Are you doing things out of habit or because they are necessary? 3. Completeness vs. Needed. Every additional procedure adds radiation to the patient! 4. We should be doing less to the patient and more for the patient. 8

9 Involved Committed 9

FLUOROSCOPIC SAFETY AND PATIENT AND OPERATOR RADIATION DOSE REDUCTION: CREATING A FOCUSED FLUOROSCOPIC CURRICULUM FOR RADIOLOGY RESIDENTS

FLUOROSCOPIC SAFETY AND PATIENT AND OPERATOR RADIATION DOSE REDUCTION: CREATING A FOCUSED FLUOROSCOPIC CURRICULUM FOR RADIOLOGY RESIDENTS Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ Abstract