Cath Lab Digest - October 2007 - (Page 22)

22 RADIATION SAFETY OCTOBER 2007 Figure 4. Biological Response to High Doses of Radiation 2,000 rad Source: "Biological Effects of Radiation" from The United States Nuclear Regulatory Commission. Accessed September 17, 2007. Available at http://www.nrc.gov/reading-rm/basic-ref/teachers/09.pdf patients that underwent procedures in the cath lab the previous day to determine if anyone exceeded the 12000 mGy in a single case. We found that while many procedures in the laboratory were well below the lower range of 460 mGy, there were some that received a much higher dose of radiation as well. With the approval of the Cardiac Catheterization Laboratory Advisory Committee (CCLAC) and the RSO, the cath lab developed and implemented action plans to reduce the amount of radiation patients received. The process began by setting all x-ray equipment to deliver 15 frames per second (fps) unless indicated otherwise by the cardiologist. The cath lab instituted a daily review of all radiation exposure doses and kept a spreadsheet in order to gather information on cumulative doses. The CCLAC instituted several arbitrary doses, at which steps are taken to try and prevent excessive radiation exposure to the patients. At 8000 mGy, the staff notifies the cardiologist of the patient’s radiation dose and at 12000 mGy, a warning is given to the cardiologist, at which time he/she may decide if the benefit of continuing the procedure outweighs the risk. Any dosage that equals or exceeds 12000 mGy is forwarded to the RSO to review. The CCLAC/RSO chose to use the arbitrary dose of 12000 mGy for notification and review by the RSO, since the calculation by the equipment is only total dose and does not take into effect many other criteria. The thinking was that it would warn the physician before 1500 rads were received and might prevent an actual sentinel event. If the RSO has to review the case, the information from the case which includes not only the dose but patient height, weight, and angles of projection and the number of frames taken with each cine run, is reviewed by the RSO and used to make a determination of whether the patient received an excessive dose to one body field. Any case that exceeds 15000 mGy to any one body part as calculated by the RSO will be subjected to a root cause analysis to determine if anything can be done in the future to prevent this occurring again and if the case constitutes a reportable sentinel event. The RSO also provides a mandatory annual radiation safety inservice to all employees and cardiology fellows who work in environments where patients are exposed to radiation. The information gathered in the beginning of this process revealed that there appeared to be less correlation than was supposed between fluoro time and the amount of radiation the equipment calculated and recorded as being received. Only one factor seemed to determine high radiation doses: difficult and complicated procedures with prolonged acquisition times. We found that potentially long procedures such as pulmonary vein ablation (PVA) and abdominal aortic aneurysm (AAA) exclusion patients received an average of only about 1000 to 2000 mGy in most cases, since electrophysiology (EP) cases primarily utilize fluoro and our physicians usually use a 7 fps setting for peripheral cases rather than the 15 to 30 fps used in coronary cases. However, in complicated and lengthy coronary interventions, the radiation dosage can exceed 6000 mGy, and in some cases, there was in excess of 8000 mGy in a single case. With the increase in multiple stents and/or multi-vessel procedures and an increase in the acuity of patients, the difficulty of the cases seemed to have increased significantly. This often translates into more lengthy acquisition times, and therefore more radiation exposure to the patient. St. Luke’s Episcopal Hospital Cath Lab’s most recent safety measure is the ability to compare the previous six months of radiation doses to the upcoming cath lab schedule in order to determine if anyone on the schedule has received a large amount of radiation cumulatively over the previous six months. This program has already allowed the cath lab to alert several physicians of a patient’s dosage before the patient received another procedure that would put them closer to possible tissue injury and/or a reportable sentinel event. Armed with this information, action plans were instituted during these cases that helped to prevent excessive radiation exposure and exceeding the limits recommended by JCAHO. Some of the options used to prevent excessive radiation have included using the last fluoro stored rather than taking as many cine runs, limiting steep angles if possible, adjusting the table height and other external steps that are within our control. Utilizing the last image fluoro stored can only be utilized in our newer rooms, since the older equipment does not have this capability. Therefore, we had to rearrange schedules so that these patient procedures could be done in one of the newer rooms. It is important to note that the “last fluoro stored” feature comes routinely with all of the newer imaging equipment, but not with older systems. Though the feature comes routinely with the software in new equipment, it is not necessarily programmed or activated (read your contract). In addition, some lab configurations may require another monitor on the boom. The cath lab also experienced some physicians opting for a different modality altogether in order to benefit the patient. The physicians routinely discuss the situation with the patient once they are notified of an upcoming procedure that may result in excessive radiation. One physician agreed to eliminate the procedure at the request of the patient once they discussed the risks and benefits of additional procedures with ionizing radiation. http://www.nrc.gov/reading-rm/basic-ref/teachers/09.pdf

Table of Contents Feed for the Digital Edition of Cath Lab Digest - October 2007

Saints Medical Center Fibromuscular Dysplasia in Children and Adolescents Cerebral Vascular Accident Following a Pulmonary Embolism: Search for the Hidden Patent Foramen Ovale Contents Clinical Editor’s Corner Meetings Calendar CEU Education Center Radiation Tracking in the Cardiac Catheterization Lab Letter to the Editor Carotid Stenting: An update Release from Stent-jail: Beneficial Snow-Plowing? Patient Management Guidelines Searching for a Cardiovascular Position? Tips for Creating a ‘Stand-Out’ Resume Long-Term Implications of Short-Term Closure Decisions – The Evolution to Vascular Access Management and the Boomerang Catalyst System The Ten-Minute Interview with… Angie Bowles, RN, CCRN CMS Issues Final FY 2008 IPPS Rule ACVP• Membership Page Experience with a New Workhorse Guidewire Ask the Clinical Instructor: Q&A for Those New to Cath Lab A Glimpse of the Future of Clinical Education: Boston Scientific’s SimSuite Bus Visits Carnegie Institute 2007 Educational Fair Held at the Washington Hospital Center Research Update: Original Contribution Abstracts from The Journal of Invasive Cardiology What Do You Think? A Virtual Cath Lab Viewer (VCL): The Development of an Online 3D C-arm Simulator and Coronary Anatomy Viewer Clinical & Industry News Cost-Effectiveness of the Radial versus Femoral Artery Approach to Diagnostic Cardiac Catheterization

Cath Lab Digest - October 2007

For optimal viewing of this digital publication, please enable JavaScript and then refresh the page. If you would like to try to load the digital publication without using Flash Player detection, please click here.