ABR PQI Summit

1. ABR PQI Summit Patient Safety Breakout August 19, 2006

2. Break Out Session:Patient Safety • ABR Trustees • Gary Becker, M.D. • Janet L. Strife, M.D. • Ann Roberts, M.D. • Participants • Linda Bresolin, PhD, RSNA • Dennis Foley, M.D., SCBT/MR • Michael Darcy, M.D., SIR • Tony Parker, M.D., ABNM • Marilyn Goske, M.D., SPR

3. ABMS Guidelines for Part 4Adopted March, 2002 • Safe • Effective • Patient-centered • Timely • Efficient • Equitable Demonstrate to patients, the public, and the profession, that physicians provide care that is:

4. 5 PQI Project Categories for DR • Practice guidelines & technical standards • Referring physician surveys • Patient safety • Double reading • Turnaround time

5. PQI timeline & milestone tracking • Draft personal Webpage PQI forms • Draft personal Webpage competency report • Iodinated contrast PQI project: objectives and metrics • Iodinated contrast PQI individual patient data form • ACR practice guideline for use of intravascular contrast media Resource Materials

6. Resource Materials • NCRP conference report: dose reduction in CT • JCAHO national patient safety goals • NQF 30 safe practices for better healthcare • IOM: preventing medication errors • MOC Part 4 in DR: slide presentation

7. Radiation safety (ALARA) • MR safety • Safe use of iodinated contrast media • Conscious sedations standards • Invasive procedure topics • -JCAHO universal protocol • -JCAHO national patient safety goals • -NQF-endorsed safe practices & voluntary consensus stds • -Prevention of central line infections • -Safe use of fluoroscopy • Prevention of medication errors Sampling of Safety Topics

8. In my busy practice, 2 of my partners and I do predominantly body CT. PQI Selection: Patient Safety Subtopic: Safe Use of Iodinated Radiographic Contrast Media

9. Data Sheet Design, Metrics • Pre-procedure evaluation • Prevention, minimization of nephrotoxicity • Prevention, minimization, management of (other) idiosyncratic reactions, anaphylaxis • Identification, management of non-idiosyncratic reactions

10. PQI ProjectSafe Use of Iodinated Contrast Material N=61 N=33 (2 with renal risk) N=6 Cr>1.5 Cr<1.5 Cr not measured Baseline Data Collection—100 Patients All 4 Lower dose 2 MRI 2 Lower dose 31 Standard Standard contrast dose Next step, improvement planning…

11. Pre-procedure evaluation • Hx from referring physician available in advance; 100% • Serum Creatinine available in advance; 100% • Prevention, minimization of nephrotoxicity in high risk patients • Pre-procedure hydration; N= • Acetylcysteine; N= • Other; N= • Selection of alternative contrast material; N= • Change examination type (eg. MRI); N= Elements of Improvement Plan

12. Prevention, minimization, management of (other) idiosyncratic reactions, anaphylaxis • Identify high-risk patients by history; 100% • Lasser or Greenberger pre-med regimen; 100% • Hx severe rxn: number benadryl + number cimetidine or ranitidine+number alternative (eg. MRI); 100% • High-risk, un-medicated, I.V. contrast; 0% • Preparedness: trained personnel, inventoried crash cart; 100% • Identification, management of non-idiosyncratic reactions • Identification of delayed reactions Elements of Improvement Plan

13. Specific Objectives with Associated Metrics PATIENT 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

14. PQI Timeline & Milestone Tracking DR Diplomates

15. PQI Timeline & Milestone Tracking DR Diplomates

16. PediatricPATIENT SAFETY Review: Imaging Practice as it applies to the Pediatric Patient

17. Goals of the Program • Radiation Safety Program of the SPR fully supports ALARA “as low as reasonable achievable”. • Individual practices/ Group practices/ or Institutions develop strategies to reduce radiation to those populations at risk and or prevent unnecessary radiation. • Utilize systems based practice evaluation, clinical guidelines when diagnostic imaging is performed. • Work towards benchmarking, national guidelines

18. Goals of Practice Performance: Pediatric Safety: SPR • Reduce Unnecessary Radiation In Populations At Risk • Evaluate Equipment and Studies to Decrease Radiation • Increase Awareness of Individual Performance Compared to Databases Concerning Radiation Exposure in Performing Studies • Standardize Approach To Patients

19. Reduce Unnecessary Radiation In Populations At RiskEquipment and Procedure Evaluation • Adjusting KV/MAS based on weight of the patient during CT imaging • Does your equipment in CT currently adjust radiation dose based on patient weight? • If the equipment does not, do you routinely adjust KV/MAS during CT imaging of pediatric patients? • Do you routinely breast shield during chest CT? • Do you routinely include the thyroid during chest imaging? • Review 25 pediatric cases

20. Reduce Unnecessary Radiation In Populations At RiskAvoid Radiation To Fetus • Pregnancy tests prior to imaging studies in child bearing ages. • Do you routinely obtain pregnancy tests prior to imaging studies such as CT, fluoroscopy, interventional cases? • Do you document that you know that the patient’s pregnancy test is negative prior to study? • Review any “sentinel” cases and document the processes initiated to decrease errors • Review 25 adolescent cases

21. Reduce Unnecessary Radiation In Populations At Risk Increasing Awareness of Radiation Dose and Standardization Of Techniques • Select a fluoroscopy study that is done and review radiation exposure • Was radiation time documented in the radiology report? • How many images were obtained on routine studies? • Benchmark your fluoroscopy time and number of images with other radiologists; local and national • Review at least 25 studies

22. Reduce Unnecessary Radiation In Populations At Risk Increasing Awareness of Radiation Dose and Standardization Of Techniques • Select a routine fluoroscopy study that is done and review imaging time and number of images • Was time documented in the radiology report? • Study selected to study • Average time per all physicians in practice vs. your time • Review at least 25 studies

23. Standardize Approach To PatientsReduce Unnecessary Studies, Appropriateness of Imaging • Select a clinical indication for a study (such as RLQ pain) • Is clinical information included in the radiology report? • Was the study that was performed appropriate for the clinical indication? • Review 25 studies and compare with institutional or ACR guidelines for Appropriateness of study

24. Standardize Approach To Patients:Reduce Unnecessary Studies, Appropriateness of Imaging • Select a known pathology/surgical diagnosis (such as appendicitis) and evaluate the imaging studies performed for appropriateness of imaging. • Is clinical information included in the radiology report? • Did radiology imaging report include the diagnosis in the report? • Was the study that was performed appropriate for the clinical indication? • Review 25 studies and compare with institutional or ACR guidelines for Appropriateness of study

28. PQI Timeline & Milestone Tracking DR Diplomates

29. PQI Timeline & Milestone Tracking DR Diplomates