Fluoroscopic Patient Dose Tracking and Follow-up at a Large ...

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Fluoroscopic Patient Dose Tracking and Follow-up at a Large ...

  1. 1. Managing Patient Fluoroscopy Dose Christopher B. Martel, CHP Director, Health Physics Radiation Safety Officer Brigham and Women’s Hospital Harvard Medical School © 2010 University at Buffalo
  2. 2. Berlin, L. Am. J. Roentgenol. 2001;177:21-25 --Headline and photograph accompanying article published in USA Today [2] reporting jury award of $1 million to 57-year-old man who sustained serious skin injury after two coronary artery angioplasties that occurred 5 months apart
  3. 3. Radiation Damage to Skin Radiation Dermatitis Radiation damage. There is loss of dermal appendages. Blood vessels are telangiectatic. (H&E)
  4. 4. Fluoroscopy Uses • Anesthesia (Pain management) • Urology • Otolaryngology (Ear, nose, throat) • Orthopedics • Interventional Radiology • Emergency Room • Cardiac Catheterization • Electrophysiology • Interventional Neuroradiology • Radiation Oncology • Neurosurgery • Surgery • Gastroenterology (Endoscopy) X-Ray Tube Image Intensifier
  5. 5. Who is getting involved? • CRCPD – State Regulations – Committee established to develop a list of reportable events (including fluoroscopy) • JCAHO Sentinel Event – Prolonged exposure to single field resulting in >1500 rads • NCRP Report 160 – Number of Interventional fluoroscopy procedures increased eight fold over past 25 years
  6. 6. Typical Regulatory Requirement • Conduct Patient Dose Evaluations • Report patient cumulative doses in single procedure > 1 Gy to Radiation Safety Committee • Dose must be entered into the patient’s medical record • Perform follow up with patients likely to have deterministic injury • Physician must have fluoroscopy priviliges
  7. 7. What’s Important? Peak Skin Dose The likelihood and severity of radiation- induced skin injury to the patient as a whole are functions of the highest radiation dose at any point on that patient’s skin—the PSD.
  8. 8. Interventional Reference Point For C-arm–type fluoroscopic systems with an isocenter, the IRP is located along the central ray of the x-ray beam at a distance of 15 cm from the isocenter in the direction of the focal spot.
  9. 9. Backscatter • Backscattered radiation contributes 27- 45% to the measurement. C J Martin 1995 Phys. Med. Biol. 40 823 S Balter 2010 Radiology 254 326-341 • Backscattered radiation contributes 25 - 40% to the measurement.
  10. 10. What methods are currently being used? • Time • GAFchromic film • Dose Mapping • Landauer Dots • Cumulative Air KERMA
  11. 11. Time • Fluoroscopy time, although still used in many healthcare institutions as an indicator for skin dose, it is widely known that there is little correlation between fluoroscopy time and skin dose.
  12. 12. GAFChromic Film • Measures surface peak skin dose • Sensitive to dose range 1cGy to 10Gy and energy range 30KeV to 30MeV. • Visually identify areas of overlap
  13. 13. Landauer Nanodots • Range is 10 mrad to 1500 rads • +/- 5% • Radiotranslucent
  14. 14. Chida, K. et al. Am. J. Roentgenol. 2006;186:774-778 Graphical display of Caregraph (Siemens Medical Solutions)
  15. 15. Cumulative AIR Kerma The air kerma accumulated at a specific point in space relative to the fluoroscopic gantry (the interventional reference point) during a procedure. CD does not include tissue backscatter and is measured in Gy. CD is sometimes referred to as cumulative air kerma. J Vasc Interv Radiol 2004; 15:423–429
  16. 16. Which method should you use? • What are you trying to do? • According to ACR: – Identify area to avoid in future procedures – Identify patients likely to develop a radiation- induced skin injury – provide follow up
  17. 17. Brigham & Women’s Hospital (BWH) Fluoro Dose Management Goals – Develop a tool that will facilitate: • Compliance with regulations • Allow monitoring of physician “performance” to guide best practices and identify opportunities for quality improvement • Allow monitoring of procedures to compare with other institutions and published data
  18. 18. BWH Results • Groups that perform fluoroscopically guided procedures with potential to exceed 1 Gray. – Electrophysiology – Cardiac Catheterization – Interventional Radiology – Interventional Neuro-radiology – Neurosurgery
  19. 19. Patient undergoes fluoroscopic guided procedure MD notes dose in patient’s medical record Procedure info added to database by MD designee Patient Fluoroscopy Dose Management and Reporting No further action required No further action required HP Reports all >1Gy exposures to RSC in bimonthly report MD gives patient discharge instructions Health Physics reviews database daily Physician schedules follow up visit in 2 to 4 weeks HP notifies Risk Management of potential Sentinel Event Risk Management reviews and makes determination Physician follows up with patient and if injury present provides referral to Dermatology < 5,000 mGy >1000 mGy > 15,000 mGy >5,000 mGy Health Physics sends letter to attending requiring follow up < 1000 mGy Physician HP
  20. 20. Desirable Features for BWH Patient Dose Tracking Program • Web-based • Secure • Editing/tracking • Searchable • Statistical Analysis • Reporting (Inventor of the Internet)
  21. 21. What we are doing • Track ALL fluoro procedures in EP, CC, IR and INR –Cumulative Air Kerma –Fluoroscopy Time –Attending Physician –MRN –Referring Physician
  22. 22. Other Features • Median dose for every procedure • Statistics for each physician by procedure • Sum fluoro doses for each patient • Record patient dose and follow-up information • Cross referenced with physician credentialing database • Drop down menus tailored to groups based on their log in
  23. 23. Dashboard
  24. 24. By Physician Physician Name Here
  25. 25. By Procedure Physician Names Here
  26. 26. Patient MRNs Here By Multiple Procedures for Individual Patients
  27. 27. Physician Names Here MRN Here Summation of Patient Cumulative Air Kerma
  28. 28. Make notes on cases
  29. 29. Interventional Reference Levels IRL = 75th Percentile AHD = (1.5 * IQR) + 75th Percentile
  30. 30. Looking at the Data • Median CAK for 38 of 39 procedures is below 500 milliGray • 75th percentile of CAK for 36 of 39 procedures is below 1,000 milliGray • Outlier CAK for 34 of 39 is below 2,000 milligray
  31. 31. Conclusions • For most interventional procedures at BWH, a CAK greater than 2,000 mGy should be rare. Exceptions are: – Percutaneous Coronary Interventions – Device upgrade ICD-CRT – Ventricular Epicardial Ablations
  32. 32. Conclusions (cont) Individual Cases >1 Gray – reported to RSC and noted in EMR >5 Gray – Follow up with patient >15 Gray – Investigation for SE Physician Data Median for procedure > 1 Gray – reported to Dept Chair for evaluation
  33. 33. Conclusions (cont) What gets measured, gets managed! • Over 8,000 cases in database so far (January 1, 2009 to present) • Developed BWH-specific Interventional Reference Levels (IRLs) • Provide quarterly reports of physician fluoro use to Department Chairs, Chief Medical Officer, individual physicians

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