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Guidelines for preceptorship in nuclear cardiology laboratories
Guidelines for preceptorship in nuclear cardiology laboratories Robert Soufer, MD, for the ASNC Training and Credentialing Committee
OVERVIEW The purpose of these guidelines is to provide the minimum standards and/or resources to provide a meaningful experience for people who participate in a preceptorship in a cardiovascular nuclear medicine laboratory. The intent of a preceptorship may vary from a review of cardiac nuclear imaging to a formal reintroduction to the field. Depending on the intent, preceptorships currently range from 1- to 2-day informal reading sessions to those lasting up to 4 months with or without correlative imaging conferences. These guidelines are not meant to replace formal ACGME training in nuclear cardiology, which results in licensure and/or certification. The purpose of this document is to provide the minimum resources, which include staffing, equipment, scope of studies, and didactic resources to provide a rich experience for the people involved in the preceptorship.
STAFFING • The Center providing a preceptorship should be directed by people who are eligible for certification or who are certified in nuclear cardiology. The laboratory should commit one person to coordinate and supervise the preceptorship and insure that candidates are exposed to the resources outlined below on a dally basis. The coordinator will meet with people halfway through and at the end of the preceptorship to monitor the progress of the candidates and the effectiveness of the program. • Technologists and nurses involved with the technical aspects of the imaging studies and/or patient care will have the appropriate training credentials in their respective fields.
LABORATORY A procedure manual that defines a standardized method of acquisition and processing of the various procedures performed in the laboratory should be present and accessible in the laboratory. It is preferable that the Reprint requests: American Societyof Nuclear Cardiology,9111 Old GeorgetownRoad, Bethesda,MD 20814-1699. J Nucl Cardiol 1997;4:420-1. Copyright © 1997 by AmericanSocietyof Nuclear Cardiology. 1071-3581/97/$5.00+0 43/1/83406 420
procedure manual conform to the guidelines in accordance with the following protocols.
Protocols • Written protocols for physical exercise according to standardized guidelines (AHA) • Written protocols for pharmacological stress according to standardized guidelines (ASNC) • Written protocols for image acquisition according to standardized guidelines (ASNC) • Written protocols for image processing according to standardized guidelines (ASNC) • Image Interpretation performed in accordance with standardized guidelines (standardized nomenclature, AHA, ACC, SNM, ASNC) • ACC/AHA/ASNC Guidelines for Clinical Use of Cardiac Radionuclide Imaging • Written protocol for emergency situations • Written radiation safety measures • Written protocol for NEMA quality assurance of equipment • Internal quality assurance program in place
SCOPE OF STUDIES A N D W O R K L O A D The variety of studies performed in the laboratory should be representative of the established and widely performed nuclear tests that provide the necessary information for clinical management. In those institutions where positron emission tomography or 511 KEV/coincidence imaging is present, availability should be tailored for the specific intent of the preceptorship. Procedures that should be available for a preceptorship are listed below and should be performed at a rate of 20 to 50 studies per week total: • Myocardial stress protocols - Exercise stress - Pharmacologic vasodilatory stress - Single-photon emission computed tomography (SPECT) with technetium agents and thallium - Planar imaging with technetium agents and thallium • Equilibrium gated blood pool imaging • First-pass radionuclide angiography (optional)
Joumal of Nuclear Cardiology Volume 4, Number5;420-1
DALLY READOUT AND CORRELATIVE CONFERENCES • Laboratories that offer preceptorships should have at least a daily didactic reading session. • Working/academic reading sessions should include ECG interpretation, pre/post test likelihood, risk stratification, visual/quantitative analysis, impact on patient management in correlation with other studies when available (cardiac catheterization, echocardiography, and physical examination). If the preceptorship is sufficiently long in duration, a follow-up with regard to management should be encouraged. • The participants of a preceptorship should be encouraged to attend other conferences that have an impact on patient management and provide a context for cardiovascular imaging studies. These conferences include catheterization, echocardiography and correlative pathology conferences.
DIRECT HANDS-ON EXPERIENCE WITH IMAGING AND PROCESSING • Camera acquisition and processing: The participants in a preceptorship should be given the opportunity to observe radiopharmaceutical preparation, administration of the dose, calibration of the imaging camera (including quality control measures), and the actual acquisition of radionuclide images. They should have the opportunity to learn computer processing and image display. These encounters should be documented in a log book and signed by the specific qualified person supervising this aspect of the training.
TEACHING RESOURCES • The laboratory should have a teaching file; it may be in a hard-copy format or digitized on a computer. It is recommended that the teaching file not merely be a summary of images with the correct interpretation but should also include various facets to enhance the learning experience. The latter would include the patient's history, ECG when appropriate and, where possible, follow-up. It is recommended that, within the teaching file, a section devoted to artifact and other technical errors be included. • Commercial sources such as CD-ROM and other software with image interpretations, follow-up, and management are recommended. • A syllabus of core reading material that would include key review articles and guidelines for the performance
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and interpretation of the studies should be on-site. In addition, this syllabus should provide articles that include a thoughtful comparison of cardiac nuclear medicine to other techniques. Guidelines for clinical use of specific studies should be included in the syllabus, such as the ACC/AHA Task Force Report, J Am Coll Cardiol 1995;25:421-47.
EVALUATION At the completion of the preceptorship, the candidate will be provided with an evaluation form that will be sent in confidence to the ASNC office. The purpose of the evaluation is to provide feedback to the centers that may enhance and/or reinforce those aspects of the preceptorship experience.
CONTINUING MEDICAL EDUCATION CME credit from the respective institutions should be available for preceptor candidates.
PET ADDENDUM The following recommendations apply to laboratories that offer cardiac PET services in addition to the procedures described above. • Centers should have active cyclotron facilities and chemistry laboratories. • Hands-on exposure to quality control measures for PET isotopes • Workload of 6-10 PET cardiac studies which include: - Resting N-13/FDG - Rest/stress perfusion • For those people who will be spending an extended period of time (at least 6 months), the PET laboratory should have an ongoing research program that encourages participation by preceptor candidates. • If a laboratory offers only a focused preceptorship in cardiac PET, all of the above recommendations apply except for those pertaining to imaging procedures listed above under "Protocols" that are not offered at the specific preceptorship. However, a procedure manual should be present and accessible in the laboratory for resting N-13/FDG and rest/stress perfusion protocols.
Approved by the ASNC Board of Directors March 17, 1997
OVERVIEW The purpose of these guidelines is to provide the minimum standards and/or resources to provide a meaningful experience for people who participate in a preceptorship in a cardiovascular nuclear medicine laboratory. The intent of a preceptorship may vary from a review of cardiac nuclear imaging to a formal reintroduction to the field. Depending on the intent, preceptorships currently range from 1- to 2-day informal reading sessions to those lasting up to 4 months with or without correlative imaging conferences. These guidelines are not meant to replace formal ACGME training in nuclear cardiology, which results in licensure and/or certification. The purpose of this document is to provide the minimum resources, which include staffing, equipment, scope of studies, and didactic resources to provide a rich experience for the people involved in the preceptorship.
STAFFING • The Center providing a preceptorship should be directed by people who are eligible for certification or who are certified in nuclear cardiology. The laboratory should commit one person to coordinate and supervise the preceptorship and insure that candidates are exposed to the resources outlined below on a dally basis. The coordinator will meet with people halfway through and at the end of the preceptorship to monitor the progress of the candidates and the effectiveness of the program. • Technologists and nurses involved with the technical aspects of the imaging studies and/or patient care will have the appropriate training credentials in their respective fields.
LABORATORY A procedure manual that defines a standardized method of acquisition and processing of the various procedures performed in the laboratory should be present and accessible in the laboratory. It is preferable that the Reprint requests: American Societyof Nuclear Cardiology,9111 Old GeorgetownRoad, Bethesda,MD 20814-1699. J Nucl Cardiol 1997;4:420-1. Copyright © 1997 by AmericanSocietyof Nuclear Cardiology. 1071-3581/97/$5.00+0 43/1/83406 420
procedure manual conform to the guidelines in accordance with the following protocols.
Protocols • Written protocols for physical exercise according to standardized guidelines (AHA) • Written protocols for pharmacological stress according to standardized guidelines (ASNC) • Written protocols for image acquisition according to standardized guidelines (ASNC) • Written protocols for image processing according to standardized guidelines (ASNC) • Image Interpretation performed in accordance with standardized guidelines (standardized nomenclature, AHA, ACC, SNM, ASNC) • ACC/AHA/ASNC Guidelines for Clinical Use of Cardiac Radionuclide Imaging • Written protocol for emergency situations • Written radiation safety measures • Written protocol for NEMA quality assurance of equipment • Internal quality assurance program in place
SCOPE OF STUDIES A N D W O R K L O A D The variety of studies performed in the laboratory should be representative of the established and widely performed nuclear tests that provide the necessary information for clinical management. In those institutions where positron emission tomography or 511 KEV/coincidence imaging is present, availability should be tailored for the specific intent of the preceptorship. Procedures that should be available for a preceptorship are listed below and should be performed at a rate of 20 to 50 studies per week total: • Myocardial stress protocols - Exercise stress - Pharmacologic vasodilatory stress - Single-photon emission computed tomography (SPECT) with technetium agents and thallium - Planar imaging with technetium agents and thallium • Equilibrium gated blood pool imaging • First-pass radionuclide angiography (optional)
Joumal of Nuclear Cardiology Volume 4, Number5;420-1
DALLY READOUT AND CORRELATIVE CONFERENCES • Laboratories that offer preceptorships should have at least a daily didactic reading session. • Working/academic reading sessions should include ECG interpretation, pre/post test likelihood, risk stratification, visual/quantitative analysis, impact on patient management in correlation with other studies when available (cardiac catheterization, echocardiography, and physical examination). If the preceptorship is sufficiently long in duration, a follow-up with regard to management should be encouraged. • The participants of a preceptorship should be encouraged to attend other conferences that have an impact on patient management and provide a context for cardiovascular imaging studies. These conferences include catheterization, echocardiography and correlative pathology conferences.
DIRECT HANDS-ON EXPERIENCE WITH IMAGING AND PROCESSING • Camera acquisition and processing: The participants in a preceptorship should be given the opportunity to observe radiopharmaceutical preparation, administration of the dose, calibration of the imaging camera (including quality control measures), and the actual acquisition of radionuclide images. They should have the opportunity to learn computer processing and image display. These encounters should be documented in a log book and signed by the specific qualified person supervising this aspect of the training.
TEACHING RESOURCES • The laboratory should have a teaching file; it may be in a hard-copy format or digitized on a computer. It is recommended that the teaching file not merely be a summary of images with the correct interpretation but should also include various facets to enhance the learning experience. The latter would include the patient's history, ECG when appropriate and, where possible, follow-up. It is recommended that, within the teaching file, a section devoted to artifact and other technical errors be included. • Commercial sources such as CD-ROM and other software with image interpretations, follow-up, and management are recommended. • A syllabus of core reading material that would include key review articles and guidelines for the performance
Sourer Guidelines for preceptorship
421
and interpretation of the studies should be on-site. In addition, this syllabus should provide articles that include a thoughtful comparison of cardiac nuclear medicine to other techniques. Guidelines for clinical use of specific studies should be included in the syllabus, such as the ACC/AHA Task Force Report, J Am Coll Cardiol 1995;25:421-47.
EVALUATION At the completion of the preceptorship, the candidate will be provided with an evaluation form that will be sent in confidence to the ASNC office. The purpose of the evaluation is to provide feedback to the centers that may enhance and/or reinforce those aspects of the preceptorship experience.
CONTINUING MEDICAL EDUCATION CME credit from the respective institutions should be available for preceptor candidates.
PET ADDENDUM The following recommendations apply to laboratories that offer cardiac PET services in addition to the procedures described above. • Centers should have active cyclotron facilities and chemistry laboratories. • Hands-on exposure to quality control measures for PET isotopes • Workload of 6-10 PET cardiac studies which include: - Resting N-13/FDG - Rest/stress perfusion • For those people who will be spending an extended period of time (at least 6 months), the PET laboratory should have an ongoing research program that encourages participation by preceptor candidates. • If a laboratory offers only a focused preceptorship in cardiac PET, all of the above recommendations apply except for those pertaining to imaging procedures listed above under "Protocols" that are not offered at the specific preceptorship. However, a procedure manual should be present and accessible in the laboratory for resting N-13/FDG and rest/stress perfusion protocols.
Approved by the ASNC Board of Directors March 17, 1997