Archives for September 2014

Creating A Patient Safety Program In A Fluoroscopy Practice

Every department performing fluoroscopically-guided procedures should take a few basic steps to ensure patient safety.  These steps are outlined in this article from FluoroSafety and Universal Medical.

Educate fluoroscope operators

Anyone operating a fluoroscope should be trained in basic fluoroscopy physics, basic radiation biology, and radiation safety.  The Basic Training Program from FluoroSafety provides this necessary didactic training for practitioners who perform simple fluoroscopic procedures, and for personnel, including nurses, anesthesia support, and others, who work in a fluoroscopy lab.

Practitioners who frequently perform fluoroscopic procedures or who perform fluoroscopically-guided interventions require training in some additional areas, including advanced fluoroscopy physics, dose monitoring, and optimizing patient dose.  The Advanced Training Program from FluoroSafety provides this training.

Situational awareness

A phrase most often heard on sports broadcasts, situational awareness is critical during fluoroscopic procedures.  Everyone involved in a fluoroscopic procedure should be aware of potentially dangerous situations, and a culture of respect and safety must be in place so anyone feels comfortable speaking up when they see a potentially dangerous situation.  For example, during fluoroscopic procedures performed with a mobile C-arm in the operating theatre, a patient’s arm may be placed dangerously close to the output port of the X-ray tube, especially if the spacer cone has been removed.  The physician is often concentrating on the medical aspects of the procedure, and may not notice that the patient is in danger.  However, a technologist or nurse may notice, and they should immediately notify the physician that the procedural setup requires modification.

Dose monitoring and audits

Every practice using fluoroscopy should be recording dose metrics from procedures and should have a process in place to review these metrics on a regular basis.  Dose metrics can be compared to national averages or other published data to identify targets for practice quality improvement.  Consider the data in the table below.  When performing nephrostomy placements, Facility A has reference air kerma values (Ka,r) that are similar to published national averages.  However, Facility A has air kerma area product (PKA) values that are substantially higher than the national average.  This could indicate that Facility A needs to pay more attention to collimation of the X-ray beam during fluoroscopic procedures.

MetricFacility ANational Average
Reference air kerma (Ka,r)250 mGy245 mGy
Air kerma area product (PKA)90 Gy-cm²49 Gy-cm²

Consent

Practices performing complex fluoroscopically-guided interventions should add a few more elements to their patient safety programs.  These elements and others are discussed in more detail in the Establishing a Patient Safety Program course from FluoroSafety.

Patients who are considering undergoing a potentially high dose fluoroscopic procedure should be explicitly informed of the risk, albeit very small, of a radiation-induced skin reaction.  This is both ethically responsible and documents that the practice informed the patient that a skin reaction was a potential risk.

Notification levels

Notification levels can be considered a particular form of situation awareness.  A notification level is a Ka,r threshold that, when reached, triggers specific actions by the practitioner.  Most importantly, a notification level is an opportunity for the operator to consider the risk/benefit pace of the procedure and to make modifications to the procedure that reduce the rate at which skin dose accumulates.  The table below is an example of notification levels for vascular and interventional radiology procedures.

Ka,r Notification Level (mGy)Suggested Action
2,500Verify Good Practice is being used
5,000 Substantial radiation dose level. Flag patient for follow up. Measure and record patient table height.
7,500Verify Good Practice. Re-evaluate risk/benefit pace of procedure, entering range of potential skin injury.
10,000Verify Good Practice. Re-evaluate risk/benefit pace of procedure. Skin injury more likely.

Follow up of patients experiencing high skin doses

A follow-up protocol should be in place for patients experiencing doses greater than a practice’s Substantial Radiation Dose Level (SRDL).  The National Council on Radiation Protection and Measurement recommends that the SRDL for Ka,r be set at 5 Gy (5,000 mGy). The follow-up protocol may include a 4-week phone or in-person follow-up, and a procedure for intensive management of patients suspected to have a skin reaction.  A procedure for tracking patients undergoing multiple or repeated high dose procedures should also be in place

About The Author:

A. Kyle Jones, PhD, DABR

Co-Founder, Fluoroscopic Safety, LLC

Dr. Kyle Jones earned his B.S. in physics from Furman University and his M.S. and Ph.D. in medical physics from the University of Florida. Dr. Jones is currently employed as a Diagnostic Medical Physicist and Assistant Professor at MD Anderson Cancer Center.

Dr. Jones is board certified in Diagnostic Medical Physics by the American Board of Radiology, is a Licensed Medical Physicist in the state of Texas, and is MQSA qualified. Dr. Jones is active in multiple research endeavors in the fields of radiation safety and diagnostic medical physics, is widely published in high impact journals, and is actively involved in teaching and training medical physics graduate students, medical physics residents, and interventional radiology fellows.

 

 

 

Avoiding Retained Surgical Items In The OR

Avoiding Serious Reportable Events (“Never Events”) In The OR

Retained Surgical Items (RSI) are included in the National Quality Forum’s list of Serious Reportable Events (commonly referred to as “Never Events”) as a, “foreign object unintentionally retained after surgery.” The Centers for Medicare & Medicaid Services (CMS) will no longer pay the extra cost of treating the following categories of conditions that occur while the patient is in the hospital. (Section 5001(c) of the Deficit Reduction Act (DRA) of 2005).

  • pressure ulcer stages III and IV;
  • falls and trauma;
  • surgical site infection after bariatric surgery for obesity, certain orthopedic procedures, and bypass surgery (mediastinitis)
  • vascular-catheter associated infection;
  • administration of incompatible blood;
  • air embolism; and
  • foreign object unintentionally retained after surgery 

The National Quality Forum (NQF) defines Never Events as errors in medical care that are of concern to both the public and health care professionals and providers, clearly identifiable and measurable (and thus feasible to include in a reporting system), and of a nature such that the risk of occurrence is significantly influenced by the policies and procedures if the health care organization.

Nothing Left Behind: A National Surgical Patient-Safety Project To Prevent Retained Surgical Items

The site www.nothingleftbehind.org is an educational resource that was started in October 2004 to work with multiple healthcare stakeholder to make sure Retained Surgical Items (RSI) become a true “never” event. The categorical classification of “foreign object unintentionally retained after surgery” may include swallowed pennies, pins, shrapnel, bullets and other objects while surgical items are the tools and materials that we use in procedures to heal not to harm¹.

Patient Safety Problem 

“More than a dozen times a day, doctors sew up patients with sponges and other supplies mistakenly left inside. The mistake can cost some victims their lives².” Although there is no federal reporting requirement, research studies and government data suggests that there are between 4,500 and 6,000 retained surgical items left in patients every year in the United States. “That’s up to twice government estimates, which run closer to 3,000 cases, and sponges account for more than two-thirds of all incidents².”

Simple Solution? 

According to Atul Gawande, a Harvard public health professor and surgeon at Boston’s Brigham and Women’s Hospital, “It’s a recurrent, persistent and nearly totally avoidable problem…There are technologies that reduce the risk, that actually reduce the overall cost (to hospitals and insurer), and yet they are not the standard. That, to me, is the shocking thing.”

Sponge-Tracking Technology

Research shows that sponges account for 67% of all surgical items mistakenly left in patients². Data complied by Medicare estimates the cost of hospitalizations involving a lost sponge or instrument at more than $60,000 per case, according to USA Today.

Why have so few hospitals adopted systems to prevent lost sponge incidences?

A USA Today survey of companies that manufacture the sponge-tracking technology found that fewer than 15% of U.S. hospitals use sponges equipped with tracking devices, which reduce the risk of leaving a sponge in a patient, that add an additional cost $8 to $12 per surgery.

Barcodes and X-Rays at U-M

Surgeons at the University of Michigan Health System created a system to prevent retained surgical items. “In its effort to be the safest hospital in the country, the U-M uses new technology to insure no objects are left behind in surgery³.” According to Ella Kazerooni, M.D., M.S., professor of radiology at the U-M and associate chair of clinical affairs at the U-M Health System, “Having a foreign object left behind during surgery is something we consider a ‘never event’. It’s something that should never happen³.”

Methods Put Into Practice

  • Bar-coded sponges – sponges have been bar-coded so that they can be scanned when they are used and again when they are taken out of the body. Computers assist the medical staff in counting and if there is a count discrepancy they will know to search the surgical field. (Bar-coded sponges also contain a radiopaque tag)
  • Electronic radiology orders – X-rays are used to find retained items while the patient is still in the OR.

“RSIs can be discovered hours to years after the initial operation and a second operation may be required for removal¹.” According to Dr.Gibbs, author of the Nothing Left Behind site (educational resource), “New ways of thinking about human error and OR practices and understanding systemic changes in OR culture are required to prevent this event. System fixes require knowledge and information, a winning strategy, consistent multi-stakeholder engagement and leadership¹.”

Preventing Future Problems

According to the Institute of Medicine, “the problem is not bad people; the problem is that the system needs to be made safer.” Some hospitals have required four counts of sponges and instruments to improve the system and reduce the number or accidents; while careful counting could prevent some mistakes, counting carries its own risks. Human error can play a major role in RSI incidences, as a majority of the cases of RSI occur under a reported correct count.

Takeaways

  • Bar coding technology can be used to improve counting and tracking sponges in the OR
  • Bar coded sponge management systems are cost-effective
  • Sponge tracking systems are part of a growing trend in which bar coding is utilized to improve the management of medical supplies, equipment and tools throughout the hospital

 

Resources: 

1. Nothing Left Behind: A National Surgical Patient Safety Project To Prevent Retained Surgical Items

http://www.nothingleftbehind.org/

2. Eisler, Peter. “What Surgeons Leave behind Costs Some Patients Dearly.”USA Today. Gannett, 08 Mar. 2013. Web. 10 Sept. 2014.

http://www.usatoday.com/story/news/nation/2013/03/08/surgery-sponges-lost-supplies-patients-fatal-risk/1969603/

3. “University of Michigan Health System Creates System to Prevent Retained Surgical Items.” Web log post. University of Michigan. N.p., 06 Feb. 2012. Web. 10 Sept. 2014.

http://www.uofmhealth.org/news/retained-surgical-items-0206

Radioprotective Garments: A Medical Physicist’s Perspective

If you read our previous blog post on ALARA, you learned that the ALARA standard used worldwide for managing dose to radiation workers actually stems from the Linear-No-Threshold (LNT) dose-response model. If the LNT model is correct, risk of deleterious effects like cancer increases linearly with radiation dose, and there is no safe amount of radiation exposure where the increased risk is zero. Because LNT suggests that there is no safe radiation dose, this motivates us to keep both our radiation dose, and the radiation dose that our patients receive very low. One of the most important ways that we, as radiation workers, accomplish ALARA is through the use of radioprotective garments. In this article from FluoroSafety and Universal Medical, several aspects of radioprotective garments will be discussed.

Radioprotective Garments

Today, radioprotective garments come in all shapes and sizes and are made from many different materials. In fact, the use of “lead aprons” to describe these garments is not quite correct, as many garments currently on the market contain no lead. Many different types of garments are used individually or in concert to protect radiation workers, including aprons, thyroid collars, vests, kilts, and protective eyewear. Let’s take a closer look at the difference between lead and lead-alternative protective garments.

Lead Protective Garments

The conventional lead apron is actually made from more than just lead; it is lead powder permanently bonded in a thick rubber or vinyl matrix allowing the apron to be flexible, comfortable, and long-lasting.  The rubber matrix is further protected by a thin vinyl covering which facilitates cleaning, while nylon straps with either Velcro or compression buckles secure it to the wearer. The protection provided by a lead garment may be quoted simply as “0.50-mm lead” or as “0.50-mm lead-equivalent”. These descriptions are interchangeable for lead garments.

A typical 0.50-mm lead apron will transmit approximately 2% of a scattered fluoroscopic X-ray beam.

Lead-Alternative Protective Garments

The product lines of most vendors now include lead-alternative radioprotective garments. Such garments may be lead-free or lead-composite. Lead-free garments use metals such as tungsten, tin, antimony, and bismuth in place of lead, while lead-alternative garments still incorporate some lead along with these other metals. The construction of lead-alternative garments is nearly identical to that of lead garments, except that metal powders other than lead are included in the rubber matrix that comprises the protective layer of the garment.

Advantages of Lead-Free Garments

Lead-free garments have two advantages over lead garments. First, lead-free garments are environmentally friendly and non-hazardous. Hospitals that replace a large number of protective garments each year may see a small cost savings because disposal of worn out lead-free garments can be handled through a conventional waste stream, while lead or lead-composite garments must be handled as hazardous waste. The second potential advantage of lead-free garments is the possibility that, by optimizing the mix of metals used in the garment, a garment that has the same performance as lead, while being lighter weight, may result. This is possible because the alternative metals used have strong absorption k-edges that closely match the energies of scattered fluoroscopic X-rays. Over a narrow range of energies, these metals attenuate radiation as well as or better than lead while being less dense, and therefore lower weight than lead. Manufacturers of such garments often advertise them as being “lighter than lead” while providing the same protection.

Determining Lead Equivalence

These are difficult claims to evaluate. Because lead-free garments do not use lead, determining the lead equivalence of such a garment is an extremely challenging problem. Recall from the last paragraph that the alternative metals absorb radiation as efficiently as lead only over a very narrow range of energies. This is one reason that a number of different metals are used, to spread this range out as much as possible. This also means that transmission of a lead-free garment depends very strongly on X-ray energy¹. Therefore, the specification of the “lead-equivalence” of such a garment at a single X-ray energy is not a complete characterization of its protective value.

Radioprotective garments typically provide the full rated protection at the front of the garment. Aprons have a single full-thickness layer while a skirt will overlap to provide the full rated thickness in the front. Most garments provide less than the full rated protection at the back (e.g., 0.25-mm), as most medical radiation workers face the source of radiation. This is an important consideration for fellows or other radiation workers who spend large amounts of time with their back facing the patient – such workers may consider purchasing a garment with at least 0.35-mm protection in the back.

Until recently, many state regulations required that personnel working around fluoroscopes wear protective garments of at least 0.50-mm lead equivalence. However, recently the National Council on Radiation Protection and Measurements, considering the tradeoff between orthopedic strain and radiation protection, suggested that 0.35 mm lead-equivalent garments are sufficient for most medical radiation workers², and state regulations are being updated to reflect this new guidance. While a typical 0.50-mm lead apron transmits approximately 2% of a typical scattered fluoroscopic X-ray beam, a 0.35-mm lead apron transmits approximately 5%. For comparison, the transmission of 0.50-mm lead-free protective garments typically ranges from 4-6%.

Lead or Lead-Free?

If you are considering changing from a lead to a lead-free garment, or from a nominal 0.50-mm garment to a nominal 0.35-mm garment, the best way to proceed is to ask your radiation safety officer or medical physicist to switch you to an EDE1 radiation monitor wear method. Using the EDE1 wear method, you will be supplied with 2 dosimeters, one worn at the collar level outside your protective garment and one at the waist level under your protective garment. This wear method allows a direct evaluation of the protective value of your new garment for your specific work environment. More details on the EDE1 wear method are available in the Advanced Training Program from FluoroSafety.

A word on weight

While it is possible that lead-free or lead-alternative garments can provide adequate protection at a reduced weight, the most important garment parameter relating to operator comfort is how well it fits. For individuals who wear protective garments every day, a custom fitted vest and kilt combination garment will result in the least orthopedic strain. After due consideration is given to the fit of the garment, the required protective value and weight of different garment options can be considered.

About The Authors:

A. Kyle Jones, PhD and Alexander S. Pasciak, PhD

Founders, Fluoroscopic Safety, LLC

Dr. Kyle Jones earned his B.S. in physics from Furman University and his M.S. and Ph.D. in medical physics from the University of Florida. Dr. Jones is currently employed as a Diagnostic Medical Physicist and Assistant Professor at MD Anderson Cancer Center.

Dr. Jones is board certified in Diagnostic Medical Physics by the American Board of Radiology, is a Licensed Medical Physicist in the state of Texas, and is MQSA qualified. Dr. Jones is active in multiple research endeavors in the fields of radiation safety and diagnostic medical physics, is widely published in high impact journals, and is actively involved in teaching and training medical physics graduate students, medical physics residents, and interventional radiology fellows.

Dr. Alexander Pasciak earned his B.S. in electrical engineering from the University of Washington and his M.Sc. in health physics and Ph.D. in nuclear engineering from Texas A&M University. Dr. Pasciak completed a two-year diagnostic medical physics residency program at MD Anderson Cancer Center in 2009.  For the past five years, Dr. Pasciak has worked as Diagnostic Medical Physicist at the University of Tennessee in Knoxville where he carries the rank of Associate Professor of Radiology.

Sources:


1. A.K. Jones, L.K. Wagner, “On the (f)utility of measuring the lead equivalence of protective garments,” Med Phys 40, 063902 (2013).

http://www.ncbi.nlm.nih.gov/pubmed/23718618

2. National Council on Radiation Protection and Measurements, Radiation dose management for fluoroscopically-guided interventional medical procedures. NCRP Report 168, (NCRP, Bethesda, MD, 2011).

http://www.ncrponline.org/Publications/Press_Releases/168press.html

Discover Gucci Radiation Resistant Glasses

Are you fashion savvy?

Have you been searching for a fashionable way to protect your eyes from the harmful effects of ionizing radiation?

Then look no further.

Gucci radiation resistant glasses have arrived. Gucci, a name synonymous with high-fashion and stylish sophistication is the latest addition to our radiation protection eyewear line.

Gucci’s styles for women range from the lightweight nylon frames of the Gucci GG 3547/S, to the bold, full-rimmed frame of the Gucci GG 3574/S.

For men, available styles include the classic Gucci GG1000/S full-rimmed acetate frame and the GG 1856/S ultra-sleek wrap frame.

Radiation resistant glasses never looked so good.

Women’s Radiation Resistant Glasses

Gucci GG 3547/S

The Gucci GG 3547/S (shown above) frames are made of lightweight, durable blended nylon for added comfort and flexibility. Unlike the brittle nylon eyeglass frames of the late 1940s, blended nylon frames are more resistant to breakage and are inherently stronger than their predecessor. Consequently, blended nylon frames are ideal for those looking for a high-quality, durable, and resilient frame.

The round shape of these frames subtly draws attention to the eyes and are well-suited for those with diamond-shaped faces. The ‘simultaneous contrast’ of the red and green temples, juxtaposing complementary colors, creates a stunning visual effect. The decorative, high-set temples are emblazoned with the iconic Gucci label (white lettering) on a bold red background. For those who have been seeking a distinctive and sophisticated pair of radiation resistant glasses, your journey finally may be nearing its end.

 

Gucci GG 3574/S

The epitome of Italian luxury, the Gucci GG 3574/S rectangular frame is bold and distinctive. The hypoallergenic black optyl frame is specially coated to resist sweat and cosmetics. These Gucci radiation resistant glasses seamlessly blend fashion, elegance, and sophistication into an integral piece of personal radiation protective equipment. A trendy frame for those who are unwilling to sacrifice style but understand the importance of properly protecting their eyes from the harmful effects of ionizing radiation.

Have you been searching for radiation eye protection that is functional, yet fashionable?

Your search is over.

These Gucci radiation resistant frames are the answer.

Offering the industry standard 0.75mm lead equivalency, the SCHOTT radiation resistant safety glass lenses will protect your eyes from the harmful effects of ionizing radiation.

According to the IAEA (International Atomic Energy Agency), “Many years or decades could pass before radiation-induced eye lens injuries become apparent. At relatively high exposures of a few Gy* , lens opacities may occur after many years¹.”

Ensure that your eyes are properly protected by wearing the appropriate radiation resistant glasses. In a 2010 study, Comparing Strategies For Operator Eye Protection In The Interventional Radiography Suite, “The use of leaded glasses alone reduced the lens dose rate by a factor of 5 to 10.” Reduce your risk of developing cataracts, while staying fashionable and safe with Gucci radiation resistant glasses.

Sources:

Thornton RH, Dauer LT, Altamirano JP, Alvardo KJ, St Germain J, Solomon SB. (2010) Comparing Strategies For Operator Eye Protection In The Interventional Radiography Suite.

http://www.ncbi.nlm.nih.gov/pubmed/20920841

IAEA | Radiation Protection of Patients (RPOP) Radiation and cataract: Staff protection

http://rpop.iaea.org/RPOP/RPoP/Content/InformationFor/HealthProfessionals/6_OtherClinicalSpecialities/radiation-cataract/Radiation-and_cataract.htm

Gray (Unit)

Wiki: http://en.wikipedia.org/wiki/Gray_(unit)

*Gy = Gray, is a derived unit of ionizing radiation dose in the International System of Units (SI). It is a measure of the absorbed dose and is defined and is defined as the absorption of one joule of radiation energy by one kilogram of matter (0.01 Gy is equivalent to 1 rad).