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Quality Improvement: Staff Radiation Exposure Reduction While Maintaining Patient Safety
Journal of Radiology Nursing xxx (2017) 1e3
Contents lists available at ScienceDirect
Journal of Radiology Nursing journal homepage: www.radiologynursing.org
Quality Improvement: Staff Radiation Exposure Reduction While Maintaining Patient Safety Nicole Jensen, RN *, Meganne Janssen, MSN, MHA, RN Department of Nursing, Mayo Clinic, Rochester, MN
a b s t r a c t Presented at the annual meeting of the Association for Radiologic & Imaging Nursing, Washington, District of Columbia, March 5 e8, 2017. Keywords: Computed tomography Extravasation Radiation Radiology nursing Safety
Radiology nurses continuously strive for improved patient safety. However, these practices may lead to unanticipated decreased staff safety. The Department of Radiology at our institution involves radiology nurses in adult and pediatric diagnostic and interventional settings. The radiology practice is a highthroughput area where almost 400 computed tomographic scans are performed daily. Nursing leadership identified an increase in quarterly dosimeter readings among staff and found that the root cause was linked to insufficient education and practices regarding radiation exposure times. The goal of the present project was to educate staff on the importance of reduced radiation exposure times. Copyright © 2017 by the Association for Radiologic & Imaging Nursing.
Introduction Computed tomography (CT) is often performed using intravenous (IV) contrast medium to enhance the imaging of normal and abnormal structures of the body (American College of Radiology [ACR] Committee on Drugs and Contrast Media, 2017). Use of IV contrast medium leads to risk of contrast extravasation. One report explains that “The reported incidence of intravenous (IV) contrast media extravasation related to power injection for CT has ranged from 0.1% to 0.9% (1/1,000 patients to 1/106 patients)” (ACR Committee on Drugs and Contrast Media, 2017, p. 20). Extravasation of contrast media can be damaging to the surrounding tissue and leads to skin ulceration, tissue necrosis, and compartment syndrome (ACR Committee on Drugs and Contrast Media, 2017). Such extravasation occurs when IV contrast medium is displaced into the extravascular space because of vessel wall puncture or rupture. It is imperative that radiology nurses are able to apply proper technique while minimizing radiation exposure to help avoid contrast medium extravasation. Proper technique includes assessing the IV for blood return and flushing it before medium injection as well as open communication with the patient during the injection so the patient can verbalize pain or the sensation of swelling (ACR Committee on Drugs and Contrast Media, 2017). The ACR Committee on Drugs and Contrast Media has stated that “A critical step in preventing significant extravasation is direct * Corresponding author: Nicole Jensen, Department of Nursing, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905. E-mail address: [email protected] (N. Jensen).
monitoring of the venipuncture site by palpation during the initial portion of the contrast medium injection” (ACR Committee on Drugs and Contrast Media, 2017, p. 17). Direct monitoring of the IV site is recommended for the first 10 to 20 s of the injection (ACR Committee on Drugs and Contrast Media, 2017; Elicker et al., 2012). Radiology nursing leadership embarked on a 6-month quality improvement project to reduce radiation exposure of CT staff by decreasing the time spent in hands-on monitoring of the IV site during contrast medium injection with a power injector. Insight was sought from a multidisciplinary team that included frontline nursing staff, technologists, radiologists, physicists, and nursing educators.
Materials and methods The team reviewed quarterly dosimeter readings for staff who worked in the CT suite directly monitoring the patient's IV site for contrast medium extravasation. The team found the whole-body, yearly cumulative, outside-of-apron readings close to the recommended yearly threshold of 5,000 mrem. Staff in the department wear one outside-of-apron monitor near their thyroid shield; pregnant staff wear an additional monitor under their apron near their abdomen. A root cause analysis and direct observations concluded that staff members were monitoring the injection site for an average of 60 s per patient because of fear of IV extravasation. Nurses shared that they were staying in the room until the contrast administration changed over to the saline flush to ensure that no contrast extravasation occurred. For many examinations, the saline
http://dx.doi.org/10.1016/j.jradnu.2017.08.003 1546-0843/$36.00/Copyright © 2017 by the Association for Radiologic & Imaging Nursing.
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N. Jensen, M. Janssen / Journal of Radiology Nursing xxx (2017) 1e3
Figure 2. Radiation safety equipment and positioning.
Figure 1. Relative scanner dose indicators for computed tomography (CT) scan rooms. MITS ¼ matrix inversion tomosynthesis.
flush occurs immediately before scanning, which leaves the nurse in the room at the beginning of scanning, exposing them to increased radiation. Cardiac images with iodinated contrast
injections were also noted to be a time when increased exposure was occurring because of the timing of the bolus and the start of imaging. Benchmarking with similar institutions and a review of current literature helped determine that injection site monitoring time could be standardized and decreased (ACR Committee on Drugs and Contrast Media, 2017; Elicker et al., 2012). A review of nursing radiation education identified gaps regarding safe distance from the gantry during imaging. We recognized that compared with the CT technologist staff, the radiology nursing staff did not receive the in-depth education on radiation safety regarding time, distance, and shielding from the gantry. New radiology nurses were getting simply a broad overview of radiation safety practices and what was available; there were no hands-on or testing of knowledge opportunities. Physicists, radiologists, and nurse educators helped to recreate the radiation reduction education by going into detail and explaining the importance of increasing the distance that staff stand from the
Figure 3. Postinjection intravenous (IV) contrast medium monitoring time. The average time was 60.24 s before staff had supplemental education; the average after education was 46.69 s. Outliers were due to questionable inadequate intravenous access or capabilities, or both.
N. Jensen, M. Janssen / Journal of Radiology Nursing xxx (2017) 1e3 Table 1 Radiation dose levels of 13 nursing staff before and after change implementation Nursing staff no.
1 2 3 4 5 6 7 8 9 10 11 12 13
Dosimeter reading, mrema Preimplementationb
First quarter postimplementationc
1,480 830 1,750 780 3,020 2,550 2,910 110 1,110 900 560 1,140 1,840
590 430 1,050 470 1,820 560 2,230 110 920 1,850 450 480 1,540
a Outliers may be due to total assigned shifts or compliance with suggested reduction measures. b Average preimplementation total dose: 1,460.0 mrem. c Average postimplementation total dose: 961.5 mrem.
gantry during imaging as well as identifying all appropriate radiation safety equipment available and how to use it. Colored lines were placed on the floor in the scanner rooms to reinforce the appropriate time and distance from the gantry (Figure 1). Radiation safety equipment was reviewed, such as lead aprons, thyroid shields, and lead eye protection, as well as lead shields on wheels used between staff and the gantry (Figure 2). In addition, an education module that included the equipment shown in Figures 1 and 2 was dispersed with a short five-question assessment to test radiation safety knowledge. Finally, a new standard of practice for monitoring the IV injection site was set at 20 s per patient and shared broadly with radiology staff. Results Data were measured again at 3 months after the practice change and education improvement. Direct observation of 70 contrast medium injections before and after the change implementation found that staff had reduced monitoring time by an average of 13 s
3
(Figure 3). Review of dosimeter readings of 13 nursing staff who had the highest initial readings found that the average radiation dose had decreased by 499 mrem (Table 1). A counterbalance measure of extravasations (>50 mL) pre- and postimplementation was reviewed and found to be neutral. Education and reinforcement of radiation reduction efforts are ongoing at our institution, and dosimeter and extravasation data are tracked on a continuous basis. Conclusion The role of the radiology nurse in the CT contrast medium administration setting is an important factor in patient safety and in reducing the risk of contrast medium extravasation. Importantly, radiology nurses need to understand their safety risks as well. Proper contrast medium administration techniques and radiation exposure education are imperative in ensuring patient and staff safety in the CT setting. The present quality improvement project results show that when staff are properly educated on radiation exposure and recommended IV site monitoring practices are established, staff radiation exposure is decreased while maintaining patient safety. Acknowledgments The authors acknowledge radiology-registered nurses, Kenneth M. Hale, Jessica L. Nelson, Julianna M. Lee, and Erin J. Loge, for their contributions to this project. Conflict of interest: None to report. Role of the funding source: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. References American College of Radiology (ACR) Committee on Drugs and Contrast Media. (2017). ACR manual on contrast media [version 10.3]. Reston, VA: American College of Radiology. Elicker, B., Coakley, F., Cho, K., Fong, C., Hampton, T., Gordon, R., et al. (2012). CT and X-ray contrast guidelines. San Francisco, CA: University of California, San Francisco (UCSF), Department of Radiology and Biomedical Imaging.
Contents lists available at ScienceDirect
Journal of Radiology Nursing journal homepage: www.radiologynursing.org
Quality Improvement: Staff Radiation Exposure Reduction While Maintaining Patient Safety Nicole Jensen, RN *, Meganne Janssen, MSN, MHA, RN Department of Nursing, Mayo Clinic, Rochester, MN
a b s t r a c t Presented at the annual meeting of the Association for Radiologic & Imaging Nursing, Washington, District of Columbia, March 5 e8, 2017. Keywords: Computed tomography Extravasation Radiation Radiology nursing Safety
Radiology nurses continuously strive for improved patient safety. However, these practices may lead to unanticipated decreased staff safety. The Department of Radiology at our institution involves radiology nurses in adult and pediatric diagnostic and interventional settings. The radiology practice is a highthroughput area where almost 400 computed tomographic scans are performed daily. Nursing leadership identified an increase in quarterly dosimeter readings among staff and found that the root cause was linked to insufficient education and practices regarding radiation exposure times. The goal of the present project was to educate staff on the importance of reduced radiation exposure times. Copyright © 2017 by the Association for Radiologic & Imaging Nursing.
Introduction Computed tomography (CT) is often performed using intravenous (IV) contrast medium to enhance the imaging of normal and abnormal structures of the body (American College of Radiology [ACR] Committee on Drugs and Contrast Media, 2017). Use of IV contrast medium leads to risk of contrast extravasation. One report explains that “The reported incidence of intravenous (IV) contrast media extravasation related to power injection for CT has ranged from 0.1% to 0.9% (1/1,000 patients to 1/106 patients)” (ACR Committee on Drugs and Contrast Media, 2017, p. 20). Extravasation of contrast media can be damaging to the surrounding tissue and leads to skin ulceration, tissue necrosis, and compartment syndrome (ACR Committee on Drugs and Contrast Media, 2017). Such extravasation occurs when IV contrast medium is displaced into the extravascular space because of vessel wall puncture or rupture. It is imperative that radiology nurses are able to apply proper technique while minimizing radiation exposure to help avoid contrast medium extravasation. Proper technique includes assessing the IV for blood return and flushing it before medium injection as well as open communication with the patient during the injection so the patient can verbalize pain or the sensation of swelling (ACR Committee on Drugs and Contrast Media, 2017). The ACR Committee on Drugs and Contrast Media has stated that “A critical step in preventing significant extravasation is direct * Corresponding author: Nicole Jensen, Department of Nursing, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905. E-mail address: [email protected] (N. Jensen).
monitoring of the venipuncture site by palpation during the initial portion of the contrast medium injection” (ACR Committee on Drugs and Contrast Media, 2017, p. 17). Direct monitoring of the IV site is recommended for the first 10 to 20 s of the injection (ACR Committee on Drugs and Contrast Media, 2017; Elicker et al., 2012). Radiology nursing leadership embarked on a 6-month quality improvement project to reduce radiation exposure of CT staff by decreasing the time spent in hands-on monitoring of the IV site during contrast medium injection with a power injector. Insight was sought from a multidisciplinary team that included frontline nursing staff, technologists, radiologists, physicists, and nursing educators.
Materials and methods The team reviewed quarterly dosimeter readings for staff who worked in the CT suite directly monitoring the patient's IV site for contrast medium extravasation. The team found the whole-body, yearly cumulative, outside-of-apron readings close to the recommended yearly threshold of 5,000 mrem. Staff in the department wear one outside-of-apron monitor near their thyroid shield; pregnant staff wear an additional monitor under their apron near their abdomen. A root cause analysis and direct observations concluded that staff members were monitoring the injection site for an average of 60 s per patient because of fear of IV extravasation. Nurses shared that they were staying in the room until the contrast administration changed over to the saline flush to ensure that no contrast extravasation occurred. For many examinations, the saline
http://dx.doi.org/10.1016/j.jradnu.2017.08.003 1546-0843/$36.00/Copyright © 2017 by the Association for Radiologic & Imaging Nursing.
2
N. Jensen, M. Janssen / Journal of Radiology Nursing xxx (2017) 1e3
Figure 2. Radiation safety equipment and positioning.
Figure 1. Relative scanner dose indicators for computed tomography (CT) scan rooms. MITS ¼ matrix inversion tomosynthesis.
flush occurs immediately before scanning, which leaves the nurse in the room at the beginning of scanning, exposing them to increased radiation. Cardiac images with iodinated contrast
injections were also noted to be a time when increased exposure was occurring because of the timing of the bolus and the start of imaging. Benchmarking with similar institutions and a review of current literature helped determine that injection site monitoring time could be standardized and decreased (ACR Committee on Drugs and Contrast Media, 2017; Elicker et al., 2012). A review of nursing radiation education identified gaps regarding safe distance from the gantry during imaging. We recognized that compared with the CT technologist staff, the radiology nursing staff did not receive the in-depth education on radiation safety regarding time, distance, and shielding from the gantry. New radiology nurses were getting simply a broad overview of radiation safety practices and what was available; there were no hands-on or testing of knowledge opportunities. Physicists, radiologists, and nurse educators helped to recreate the radiation reduction education by going into detail and explaining the importance of increasing the distance that staff stand from the
Figure 3. Postinjection intravenous (IV) contrast medium monitoring time. The average time was 60.24 s before staff had supplemental education; the average after education was 46.69 s. Outliers were due to questionable inadequate intravenous access or capabilities, or both.
N. Jensen, M. Janssen / Journal of Radiology Nursing xxx (2017) 1e3 Table 1 Radiation dose levels of 13 nursing staff before and after change implementation Nursing staff no.
1 2 3 4 5 6 7 8 9 10 11 12 13
Dosimeter reading, mrema Preimplementationb
First quarter postimplementationc
1,480 830 1,750 780 3,020 2,550 2,910 110 1,110 900 560 1,140 1,840
590 430 1,050 470 1,820 560 2,230 110 920 1,850 450 480 1,540
a Outliers may be due to total assigned shifts or compliance with suggested reduction measures. b Average preimplementation total dose: 1,460.0 mrem. c Average postimplementation total dose: 961.5 mrem.
gantry during imaging as well as identifying all appropriate radiation safety equipment available and how to use it. Colored lines were placed on the floor in the scanner rooms to reinforce the appropriate time and distance from the gantry (Figure 1). Radiation safety equipment was reviewed, such as lead aprons, thyroid shields, and lead eye protection, as well as lead shields on wheels used between staff and the gantry (Figure 2). In addition, an education module that included the equipment shown in Figures 1 and 2 was dispersed with a short five-question assessment to test radiation safety knowledge. Finally, a new standard of practice for monitoring the IV injection site was set at 20 s per patient and shared broadly with radiology staff. Results Data were measured again at 3 months after the practice change and education improvement. Direct observation of 70 contrast medium injections before and after the change implementation found that staff had reduced monitoring time by an average of 13 s
3
(Figure 3). Review of dosimeter readings of 13 nursing staff who had the highest initial readings found that the average radiation dose had decreased by 499 mrem (Table 1). A counterbalance measure of extravasations (>50 mL) pre- and postimplementation was reviewed and found to be neutral. Education and reinforcement of radiation reduction efforts are ongoing at our institution, and dosimeter and extravasation data are tracked on a continuous basis. Conclusion The role of the radiology nurse in the CT contrast medium administration setting is an important factor in patient safety and in reducing the risk of contrast medium extravasation. Importantly, radiology nurses need to understand their safety risks as well. Proper contrast medium administration techniques and radiation exposure education are imperative in ensuring patient and staff safety in the CT setting. The present quality improvement project results show that when staff are properly educated on radiation exposure and recommended IV site monitoring practices are established, staff radiation exposure is decreased while maintaining patient safety. Acknowledgments The authors acknowledge radiology-registered nurses, Kenneth M. Hale, Jessica L. Nelson, Julianna M. Lee, and Erin J. Loge, for their contributions to this project. Conflict of interest: None to report. Role of the funding source: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. References American College of Radiology (ACR) Committee on Drugs and Contrast Media. (2017). ACR manual on contrast media [version 10.3]. Reston, VA: American College of Radiology. Elicker, B., Coakley, F., Cho, K., Fong, C., Hampton, T., Gordon, R., et al. (2012). CT and X-ray contrast guidelines. San Francisco, CA: University of California, San Francisco (UCSF), Department of Radiology and Biomedical Imaging.