ABR PQI Summit Patient Safety Breakout August 19, 2006.

ABR PQI SummitABR PQI SummitPatient Safety BreakoutPatient Safety Breakout

August 19, 2006August 19, 2006

Break Out Session:Break Out Session:Patient SafetyPatient Safety

ABR TrusteesABR Trustees Gary Becker, M.D.Gary Becker, M.D. Janet L. Strife, M.D.Janet L. Strife, M.D. Ann Roberts, M.D.Ann Roberts, M.D.

ParticipantsParticipants Linda Bresolin, PhD, RSNALinda Bresolin, PhD, RSNA Dennis Foley, M.D., SCBT/MRDennis Foley, M.D., SCBT/MR Michael Darcy, M.D., SIRMichael Darcy, M.D., SIR Tony Parker, M.D., ABNMTony Parker, M.D., ABNM Marilyn Goske, M.D., SPRMarilyn Goske, M.D., SPR

ABMS Guidelines for ABMS Guidelines for Part 4Part 4

Adopted March, 2002Adopted March, 2002Demonstrate to patients, the Demonstrate to patients, the

public, and the profession, that public, and the profession, that physicians provide care that is:physicians provide care that is: SafeSafe

EffectiveEffective Patient-Patient-centeredcentered TimelyTimely EfficientEfficient EquitableEquitable

5 PQI Project Categories for 5 PQI Project Categories for DRDR

Practice guidelines & technical Practice guidelines & technical standardsstandards

Referring physician surveysReferring physician surveys Patient safetyPatient safety Double reading Double reading Turnaround timeTurnaround time

Resource MaterialsResource Materials PQI timeline & milestone trackingPQI timeline & milestone tracking Draft personal Webpage PQI formsDraft personal Webpage PQI forms Draft personal Webpage competency Draft personal Webpage competency reportreport Iodinated contrast PQI project: Iodinated contrast PQI project: objectives and objectives and metricsmetrics Iodinated contrast PQI individual Iodinated contrast PQI individual patient datapatient data form form ACR practice guideline for use of ACR practice guideline for use of intravascular intravascular contrast mediacontrast media

Resource MaterialsResource Materials NCRP conference report: dose NCRP conference report: dose reduction in CTreduction in CT JCAHO national patient safety goalsJCAHO national patient safety goals NQF 30 safe practices for better NQF 30 safe practices for better healthcarehealthcare IOM: preventing medication errorsIOM: preventing medication errors MOC Part 4 in DR: slide MOC Part 4 in DR: slide presentationpresentation

Sampling of Safety Sampling of Safety TopicsTopics Radiation safety (ALARA)Radiation safety (ALARA)

MR safetyMR safety Safe use of iodinated contrast Safe use of iodinated contrast mediamedia Conscious sedations standardsConscious sedations standards Invasive procedure topicsInvasive procedure topics

-JCAHO universal protocol-JCAHO universal protocol

-JCAHO national patient safety goals-JCAHO national patient safety goals

-NQF-endorsed safe practices & voluntary -NQF-endorsed safe practices & voluntary consensus stdsconsensus stds

-Prevention of central line infections-Prevention of central line infections

-Safe use of fluoroscopy-Safe use of fluoroscopy

Prevention of medication errorsPrevention of medication errors

In my busy practice, 2 of my In my busy practice, 2 of my partners and I do partners and I do

predominantly body CT.predominantly body CT.

PQI Selection: Patient PQI Selection: Patient SafetySafety

Subtopic: Safe Use of Iodinated Subtopic: Safe Use of Iodinated Radiographic Contrast MediaRadiographic Contrast Media

Data Sheet Design, Data Sheet Design, MetricsMetrics

Pre-procedure evaluationPre-procedure evaluation Prevention, minimization of Prevention, minimization of nephrotoxicitynephrotoxicity Prevention, minimization, Prevention, minimization, management of management of (other) (other) idiosyncratic reactions, anaphylaxisidiosyncratic reactions, anaphylaxis Identification, management of non-Identification, management of non-idiosyncraticidiosyncratic reactions reactions

PQI ProjectPQI ProjectSafe Use of Iodinated Contrast Safe Use of Iodinated Contrast

MaterialMaterialBaseline Data Collection—100 Baseline Data Collection—100

PatientsPatientsN=6

Cr>1.5

N=61

Cr<1.5

N=33(2 with renal

risk)Cr not

measured

2 MRI

4 Lowe

r dose

All

Standard contrast dose

2 Lower dose31 Standard

Next step, improvement planning…

Elements of Elements of Improvement PlanImprovement Plan Pre-procedure evaluationPre-procedure evaluation

Hx from referring physician available in Hx from referring physician available in advance; 100%advance; 100%Serum Creatinine available in advance; 100%Serum Creatinine available in advance; 100%

Prevention, minimization of Prevention, minimization of nephrotoxicity in nephrotoxicity in high risk patientshigh risk patients

Pre-procedure hydration; N=Pre-procedure hydration; N=Acetylcysteine; N=Acetylcysteine; N=Other; N=Other; N=Selection of alternative contrast material; N=Selection of alternative contrast material; N=Change examination type (eg. MRI); N=Change examination type (eg. MRI); N=

Elements of Elements of Improvement PlanImprovement Plan Prevention, minimization, Prevention, minimization,

management of management of (other) (other) idiosyncratic reactions, anaphylaxisidiosyncratic reactions, anaphylaxis

Identify high-risk patients by history; 100%Identify high-risk patients by history; 100%Lasser or Greenberger pre-med regimen; 100%Lasser or Greenberger pre-med regimen; 100%Hx severe rxn: number benadryl + number Hx severe rxn: number benadryl + number cimetidine or cimetidine or ranitidine+number alternative ranitidine+number alternative (eg. MRI); 100%(eg. MRI); 100%High-risk, un-medicated, I.V. contrast; 0%High-risk, un-medicated, I.V. contrast; 0%Preparedness: trained personnel, inventoried Preparedness: trained personnel, inventoried crash cart; 100%crash cart; 100%

Identification, management of non-Identification, management of non-idiosyncraticidiosyncratic reactions reactionsIdentification of delayed reactionsIdentification of delayed reactions

Specific Objectives with Associated MetricsPATIENT SAFETY Safe Use of Iodinated Radiographic Contrast Media (RCM)

Consecutive Cases to be used: Baseline – 100; Improvement data sets: 1st – 200, 2nd – 300, 3rd – 400

SPECIFIC OBJECTIVEMETRICS REPORT AS:

1) Pre-procedure evaluation

a. History: 1. contrast reaction: nature, severity; 2. allergy, hayfever, asthma; 3. diabetes, 4. heart disease (recent/imminent cardiac decompensation, dysrhythmia, unstable angina, recent MI, pulmonary hypertension); 5. generalized debilitation; 6. renal risk: renal insufficiency, current nephrotoxic medications, multiple myeloma; 7. pregnancy b. Serum creatinine [at risk groups benefit from LOCM]

a. counts: at risk, not at risk, unknownb. counts: Cr obtained (Y/N)

2) Prevention, minimization of nephrotoxicity

a. Patients not at risk for nephrotoxicityb. Pre-procedure identification of patients at risk for nephrotoxicityc. For those at risk, action taken: 1. None, 2. Lower dose, 3. Other contrast (eg. LOCM) selected, 4. Combo of 2&3, 5. Procedure done without contrast, 6. Different (eg.MRI)d. For those at risk, number who received pre- & post-procedure hydratione. For those at risk, other steps taken to amelioratef. For those at risk, specific follow-up communication with referring physician

a: contrast, dose_______b-d: countse: drugs, doses, countsf. counts

3) Prevention, minimization, management of idiosyncratic reactions, anaphylaxis

a. General preparedness for idiosyncratic / anaphylactic contrast reaction 1. Physician in immediate vicinity and available 2. CT physicians, nurses trained in management of contrast reactions 3. Inventoried crash cart in room for each contrast administrationb. Identification of patients with hx contrast reaction, food or medication allergy, hay fever or asthmac. Use of Lasser or Greenberger pre-medication regimen in at-risk patients: 1. 32mg methylprednisolone p.o. 12hr and 2hr pre-procedure, or: 2. 50mg prednisone p.o. 13hrs, 7hrs, and 1hr pre-procedured. Of patients with a history of contrast reaction, number of moderate to severe 1. Number of moderate to severe receiving Lasser/Greenberger+diphenhydramine 50mg 1hr pre- 2. Number of moderate to severe receiving Lasser/Greenberger+cimetidine or ranitidine 1hr pre- 3. Number of patients undergoing alternative procedure without RCMe. Number of contrast reactions that occurredf. Diagnosis and management of reactions that occurred (sxs, signs, Tx: drugs, doses, outcomes)

a.1-3: Countsb: counts (at risk, not at risk, unknown)c: countsd. 1-2: Countsd. 3: list alternative procedures and countse: countsf: sxs, signs, Tx, outcome

4) Identification and management of non-idiosyncratic reactions

Bradycardia, hypotension, vasovagal reaction, nausea, vomiting, diaphoresis, sphincter dysfunction, seizure, mental status changes, extravasation

count, sxs, signs, Tx, outcome

5) Identification of delayed reactions (30 min to 7 days post; almost all resolve spontaneously)

Fever, chills, pruritus, nausea, vomiting, diarrhea, abdominal pain, pain in injected limb, rash, dizziness, headache, parotitis, arthropathy, constipation, depressiona. Practice captures delayed reactions that occurb. Captured delayed reactions

a. count (Y/N)b. count, type, sxs, signs, Tx, outcome

PQI Timeline & Milestone PQI Timeline & Milestone TrackingTrackingDR DiplomatesDR Diplomates

Year of Cycle

What I must do each year of 10-year MOC cycle Submit report / attestation via the Personal Web Page

1

Select project and metric(s)Collect, analyze baseline data Yes

2Develop improvement plan Implement planBegin collecting improvement plan data

Yes

3

Complete collection of improvement plan dataAnalyze dataSummarize data

Yes

4

Modify improvement planImplement planBegin collecting improvement plan data

Yes

5 Continue collecting data Yes


Year of Cycle


6


Yes

7Refine improvement planImplement planBegin collecting improvement plan data

Yes


9


Yes

10

Prepare final report of results and conclusionsSustain the gain of 1st cycleSelect topic for next cycle

Yes

PediatricPediatricPATIENT SAFETYPATIENT SAFETY

Review: Imaging Practice Review: Imaging Practice as it applies to the as it applies to the Pediatric PatientPediatric Patient

Goals of the ProgramGoals of the Program Radiation Safety Program of the SPR fully Radiation Safety Program of the SPR fully

supports ALARA “as low as reasonable supports ALARA “as low as reasonable achievable”. achievable”.

Individual practices/ Group practices/ or Individual practices/ Group practices/ or Institutions develop strategies to reduce radiation Institutions develop strategies to reduce radiation to those populations at risk and or prevent to those populations at risk and or prevent unnecessary radiation. unnecessary radiation.

Utilize systems based practice evaluation, clinical Utilize systems based practice evaluation, clinical guidelines when diagnostic imaging is performed. guidelines when diagnostic imaging is performed.

Work towards benchmarking, national guidelines Work towards benchmarking, national guidelines

Goals of Practice Goals of Practice Performance: Performance:

Pediatric Safety: SPR Pediatric Safety: SPR Reduce Unnecessary Radiation In Reduce Unnecessary Radiation In

Populations At RiskPopulations At Risk Evaluate Equipment and Studies to Evaluate Equipment and Studies to

Decrease RadiationDecrease Radiation Increase Awareness of Individual Increase Awareness of Individual

Performance Compared to Databases Performance Compared to Databases Concerning Radiation Exposure in Concerning Radiation Exposure in Performing StudiesPerforming Studies

Standardize Approach To PatientsStandardize Approach To Patients

Reduce Unnecessary Radiation In Populations At RiskReduce Unnecessary Radiation In Populations At Risk

Equipment and Procedure EvaluationEquipment and Procedure Evaluation

Adjusting KV/MAS based on weight of the patient Adjusting KV/MAS based on weight of the patient during CT imaging during CT imaging Does your equipment in CT currently adjust radiation Does your equipment in CT currently adjust radiation

dose based on patient weight?dose based on patient weight? If the equipment does not, do you routinely adjust If the equipment does not, do you routinely adjust

KV/MAS during CT imaging of pediatric patients?KV/MAS during CT imaging of pediatric patients? Do you routinely breast shield during chest CT?Do you routinely breast shield during chest CT? Do you routinely include the thyroid during chest Do you routinely include the thyroid during chest

imaging?imaging? Review 25 pediatric casesReview 25 pediatric cases


Avoid Radiation To FetusAvoid Radiation To Fetus

Pregnancy tests prior to imaging studies in Pregnancy tests prior to imaging studies in child bearing ages.child bearing ages. Do you routinely obtain pregnancy tests prior to Do you routinely obtain pregnancy tests prior to

imaging studies such as CT, fluoroscopy, imaging studies such as CT, fluoroscopy, interventional cases?interventional cases?

Do you document that you know that the Do you document that you know that the patient’s pregnancy test is negative prior to patient’s pregnancy test is negative prior to study?study?

Review any “sentinel” cases and document the Review any “sentinel” cases and document the processes initiated to decrease errorsprocesses initiated to decrease errors

Review 25 adolescent casesReview 25 adolescent cases


Increasing Awareness of Radiation Dose and Increasing Awareness of Radiation Dose and Standardization Of TechniquesStandardization Of Techniques

Select a fluoroscopy study that is done and review Select a fluoroscopy study that is done and review radiation exposureradiation exposure Was radiation time documented in the radiology report? Was radiation time documented in the radiology report? How many images were obtained on routine studies?How many images were obtained on routine studies? Benchmark your fluoroscopy time and number of Benchmark your fluoroscopy time and number of

images with other radiologists; local and nationalimages with other radiologists; local and national Review at least 25 studiesReview at least 25 studies

Select a routine fluoroscopy study that is done and Select a routine fluoroscopy study that is done and review imaging time and number of imagesreview imaging time and number of images Was time documented in the radiology report? Was time documented in the radiology report? Study selected to studyStudy selected to study Average time per all physicians in practice vs. your timeAverage time per all physicians in practice vs. your time

Review at least 25 studiesReview at least 25 studies


Increasing Awareness of Radiation Dose and Increasing Awareness of Radiation Dose and Standardization Of Techniques Standardization Of Techniques

Standardize Approach To PatientsStandardize Approach To Patients

Reduce Unnecessary Studies, Appropriateness of ImagingReduce Unnecessary Studies, Appropriateness of Imaging

Select a clinical indication for a study (such as RLQ Select a clinical indication for a study (such as RLQ pain) pain) Is clinical information included in the radiology Is clinical information included in the radiology

report?report? Was the study that was performed appropriate for Was the study that was performed appropriate for

the clinical indication?the clinical indication? Review 25 studies and compare with institutional or Review 25 studies and compare with institutional or

ACR guidelines for Appropriateness of studyACR guidelines for Appropriateness of study

Standardize Approach To Patients:Standardize Approach To Patients:

Reduce Unnecessary Studies, Appropriateness of Imaging Reduce Unnecessary Studies, Appropriateness of Imaging

Select a known pathology/surgical diagnosis (such as Select a known pathology/surgical diagnosis (such as appendicitis) and evaluate the imaging studies appendicitis) and evaluate the imaging studies performed for appropriateness of imaging.performed for appropriateness of imaging. Is clinical information included in the radiology report?Is clinical information included in the radiology report? Did radiology imaging report include the diagnosis in Did radiology imaging report include the diagnosis in

the report?the report? Was the study that was performed appropriate for the Was the study that was performed appropriate for the

clinical indication?clinical indication? Review 25 studies and compare with institutional or Review 25 studies and compare with institutional or

ACR guidelines for Appropriateness of studyACR guidelines for Appropriateness of study

SPECIFIC OBJECTIVESPECIFIC OBJECTIVE METRICSMETRICS REPORT ASREPORT AS

Adjusting KV/MAS Adjusting KV/MAS based on weight of based on weight of the patient during the patient during CT imaging. CT imaging.

Goal: Reduce Goal: Reduce unnecessary unnecessary radiation in radiation in populations at riskpopulations at risk..

Does your equipment currently in CT adjust Does your equipment currently in CT adjust radiation dose based on patient weight?radiation dose based on patient weight?

If the equipment does not, do you routinely adjust If the equipment does not, do you routinely adjust KV/MAS during CT imaging of pediatric KV/MAS during CT imaging of pediatric patients.patients.

Review 25 pediatric cases; Review 25 pediatric cases;

Yes NoYes NoYes NoYes NoPercent compliance Percent compliance

Utilize breast shielding in Utilize breast shielding in young patientsyoung patients

Goal: Reducing Goal: Reducing unnecessary unnecessary radiation to the radiation to the breast.breast.

Do you routinely utilize breast shielding in young Do you routinely utilize breast shielding in young patients during CT;patients during CT;

Review 25 pediatric cases;Review 25 pediatric cases;

Yes NoYes NoPercent compliance Percent compliance

Pregnancy tests prior to Pregnancy tests prior to imaging studies in imaging studies in child bearing ages.child bearing ages.

Goal: Avoid radiation to Goal: Avoid radiation to fetus and increase fetus and increase awareness of the awareness of the issues.issues.

Do you routinely obtain pregnancy tests prior to Do you routinely obtain pregnancy tests prior to imaging studies such as CT, fluoroscopy, imaging studies such as CT, fluoroscopy, interventional cases?interventional cases?

Do you document that you know that the patient’s Do you document that you know that the patient’s pregnancy test is negative prior to study?pregnancy test is negative prior to study?

Review 25 pediatric, adolescent or child bearing Review 25 pediatric, adolescent or child bearing adult casesadult cases



Select a fluoroscopy study Select a fluoroscopy study that is done and review that is done and review fluoroscopy timefluoroscopy timeGoal: Increase Goal: Increase awareness, awareness, standardization of standardization of techniques, opportunities techniques, opportunities to reduce dose by to reduce dose by decreasing time.decreasing time.

Was time documented in the radiology report? Was time documented in the radiology report? Study selected to studyStudy selected to studyAverage time per all physicians in practice vs. your Average time per all physicians in practice vs. your timetimeReview at least 25 studies.Review at least 25 studies.

Yes NoYes NoName of studyName of studyTime in minutesTime in minutes

Select an interventional Select an interventional study that is done and study that is done and review imaging timereview imaging timeGoal: Increase Goal: Increase awareness, awareness, standardization of standardization of techniques, opportunities techniques, opportunities to reduce dose by to reduce dose by decreasing time.decreasing time.

Was time documented in the radiology report? Was time documented in the radiology report? Study selected to studyStudy selected to studyAverage time per all physicians in practice vs. your Average time per all physicians in practice vs. your timetimeReview at least 25 studies.Review at least 25 studies.

Yes NoYes NoName of studyName of studyTime in minutesTime in minutes

Select a clinical indication Select a clinical indication for a study (such as RLQ for a study (such as RLQ pain) pain) Goal: Standardize Goal: Standardize approach to patients to approach to patients to reduce unnecessary reduce unnecessary studiesstudies

Is clinical information included in the radiology Is clinical information included in the radiology report?report?Was the study that was performed appropriate for Was the study that was performed appropriate for the clinical indication?the clinical indication?Review 25 studies and compare with institutional or Review 25 studies and compare with institutional or ACR guidelines for Appropriateness of studyACR guidelines for Appropriateness of study



Select an imaging Select an imaging diagnosis (such as diagnosis (such as appendicitis) and review appendicitis) and review the imaging studies to see the imaging studies to see if the study was if the study was appropriate.appropriate.Goal: Standardize Goal: Standardize approach to patients to approach to patients to reduce radiation by reduce radiation by insuring appropriateness insuring appropriateness of imaging studiesof imaging studies

Is clinical information included in the radiology Is clinical information included in the radiology report?report?Was the study that was performed appropriate for Was the study that was performed appropriate for the clinical indication?the clinical indication?Review 50 studies and compare with institutional Review 50 studies and compare with institutional or ACR guidelines for Appropriateness of studyor ACR guidelines for Appropriateness of study


Select a known pathology Select a known pathology diagnosis (such as diagnosis (such as appendicitis) and evaluate appendicitis) and evaluate the imaging studies the imaging studies performed for performed for appropriateness of imaging.appropriateness of imaging.Goal: Standardize Goal: Standardize approach to patients to approach to patients to reduce radiation by reduce radiation by insuring appropriateness insuring appropriateness of imaging studiesof imaging studies

Is clinical information included in the radiology Is clinical information included in the radiology report?report?Did radiology imaging report include the diagnosis Did radiology imaging report include the diagnosis in the report?in the report?Was the study that was performed appropriate for Was the study that was performed appropriate for the clinical indication?the clinical indication?Review 20-50 studies and compare with Review 20-50 studies and compare with institutional or ACR guidelines for institutional or ACR guidelines for Appropriateness of studyAppropriateness of study

Yes NoYes NoYes NoYes NoYes NoYes NoPercent compliance Percent compliance


Year of Cycle


1

Select project and metric(s)Collect, analyze baseline data Yes

2Develop improvement plan Implement planBegin collecting improvement plan data

Yes

3


Yes

4

Modify improvement planImplement planBegin collecting improvement plan data

Yes



Year of Cycle


6


Yes

7Refine improvement planImplement planBegin collecting improvement plan data

Yes


9


Yes

10

Prepare final report of results and conclusionsSustain the gain of 1st cycleSelect topic for next cycle

Yes

ABR PQI Summit Patient Safety Breakout August 19, 2006.

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Transcript of ABR PQI Summit Patient Safety Breakout August 19, 2006.