Northern California SGNA Meeting September 22, 2012

1. Northern CaliforniaSGNA MeetingSeptember 22, 2012

2. Radiation safetyin theERCP suite

3. Disclosure Statement Product Specialist for Core Medical Imaging Distributor of Omega’s E-view system for ERCP studies

4. Radiation Safety in the ERCP suite Endoscopic Retrograde CholangioPancreatography Fluoroscopy

5. Radiation Safety in the ERCP suite Objectives: To discuss: Four equipment configurations Basics of x-ray Scatter radiation Minimize radiation dose

6. Radiation Safety in the ERCP suite Today’s goal: Understand fluoroscopy to: Compliment exam Minimize radiation exposure

7. Radiation Safety in the ERCP suite Why are these goals important to a Nurse?

8. Radiation Safety in the ERCP suite Radiating the patient is part of “Patient Care!”

9. Radiation Safety in the ERCP suite What is Fluoroscopy? (in English)

10. Radiation Safety in the ERCP suite What is Fluoroscopy? • Low dose x-ray image • Taken at 30,15 or 7.5 times/sec • Displayed at 30 frames/sec

11. Radiation Safety in the ERCP suite 2 Radiation items you need to know: #1 Less is better #2 Inverse square law

12. Radiation Safety in the ERCP suite 2 Radiation items you need to know: #1 Radiation - Less is better (= image quality)

13. Radiation Safety in the ERCP suite Radiation: the opposite of chocolate

14. Radiation Safety in the ERCP suite 2 Radiation items you need to know: #2 Inverse square law

15. Radiation Safety in the ERCP suite Inverse square law: 2 x the distance =’s 4 x the radiation

16. Radiation Safety in the ERCP suite Inverse square law: 3 x the distance =’s 9 x the radiation

17. Radiation Safety in the ERCP suite Application of Inverse Square law Image Intensifier - close to patient as possible. X-ray tube – far away from patient as possible.

18. Radiation Safety in the ERCP suite Equipment Configurations

19. Radiation Safety in the ERCP suite

20. Radiation Safety in the ERCP suite 4 equipment configurations do 98.56% of all ERCP’s

21. Radiation Safety in the ERCP suite 47.07% of exams ERCP Modalities - Portable C-arm

22. Radiation Safety in the ERCP suite Portable C-arm Advantages: • Least cost (~$225,000) • Every hospital has 1 or 2 or 3 • Tube angulation

23. Tube angulation Image viewed straight on Cystic Duct superimposed C-Arm angled to view Cystic Duct

24. Radiation Safety in the ERCP suite Portable C-arm Dis-advantages: • Image quality • Radiation dose • Slow/hard to use

25. Radiation Safety in the ERCP suite ERCP Modalities - Rad/Fluoro room 28.52% of exams

26. Radiation Safety in the ERCP suite Rad/Fluoro room Advantages: • Image quality • Radiation dose • Moderate expense ($300K - $325K)

27. Radiation Safety in the ERCP suite Rad/Fluoro room Dis-advantages: • No tube angulation • Non elevating table • Patient orientation

28. Radiation Safety in the ERCP suite ERCP Modality - Multi Purpose room 17.24% of exams

29. Radiation Safety in the ERCP suite Multi Purpose room Advantages: • Image quality • Radiation dose • Tube angulation • Elevating table

30. Radiation Safety in the ERCP suite Multi Purpose room Dis-advantages: • Equipment cost ($550K+) • Complexity • Room size

31. Radiation Safety in the ERCP suite 2.72% of exams ERCP Modalities Dedicated designed

32. Radiation Safety in the ERCP suite Dedicated designed Advantages: • Image quality • Radiation dose • Tube angulation • Elevating table

33. Radiation Safety in the ERCP suite Dedicated designed Dis-advantages: • Cost $400K

34. Radiation Safety in the ERCP suite Scatter Radiation Why is it important?

35. Radiation Safety in the ERCP suite • WGO 2009 • “For endoscopists and staff, the major source of x-ray exposure is scattered radiation from the patient, not the primary x-ray beam.”

36. Radiation Safety in the ERCP suite <1% Table top 98+% Patient <1% Image Int.

37. Radiation Safety in the ERCP suite Scatter Radiation How to minimize it

38. Radiation Safety in the ERCP suite Minimize Radiation Dose Lead Shielding

39. Radiation Safety in the ERCP suite Table drape for nurses

40. Radiation Safety in the ERCP suite Minimize Radiation Dose Pay attention to the fluoro dose readout device

41. Radiation Safety in the ERCP suite Minimize Radiation Dose Required in 2006 Display results

42. WGO Guidelines http://www.worldgastroenterology.org/assets/downloads/en/pdf/guidelines/23_wgo_radiation_protection_in_endo_suite_en.pdf

43. WGO Guidelines Level 1: high resource levels Level 2: average resource levels Level 3: minimum resource levels

44. WGO Guidelines • Use of proper technique to minimize the radiation dose to the patient (e.g., keeping the x-ray tube as far away from the patient as possible and the image receptor as close as feasible, …)

45. Radiation Safety in the ERCP suite Summary 1) Radiation – less is better 2) Use Inverse square law 3) Proper shielding

46. Radiation Safety in the ERCP suite Questions?

47. Radiation Safety in the ERCP suite References Slide # 10 – WGO Practice Guideline: Radiation protection in the endoscopy suite Slide # 20 – Survey conducted by Don Dockter Slide # 21 – Survey conducted by Don Dockter Slide # 25 – Survey conducted by Don Dockter Slide # 28 – Survey conducted by Don Dockter Slide # 31 – Survey conducted by Don Dockter

48. Radiation Safety in the ERCP suite References Slide # 36 – Mr. James Princehorn, President Omega Medical – WGO Practice Guideline: Radiation protection in the endoscopy suite Slide # 41– 21CFR, part 1020.32 all diagnostic x-ray device must display Entrance Air Kerma Rate, Accumulated Air Kerma, and Accumulated Fluoro Time. Slide # 44 – WGO Practice Guideline: Radiation protection in the endoscopy suite