Intraoperative and interventional MRI: recommendations for a safe environment.

In this paper we report on current experience and review magnetic resonance safety protocols and literature in order to define practices surrounding MRI-guided interventional and surgical procedures. Direct experience, the American College of Radiology White paper on MR Safety, and various other sources are summarized. Additional recommendations for interventional and surgical MRI-guided procedures cover suite location/layout, accessibility, safety policy, personnel training, and MRI compatibility issues. Further information is freely available for sites to establish practices to minimize risk and ensure safety. Interventional and intraoperative MRI is emerging from its infancy, with twelve years since the advent of the field and well over 10,000 cases collectively performed. Thus, users of interventional and intraoperative MRI should adapt guidelines utilizing universal standards and terminology and establish a site-specific policy. With policy enforcement and proper training, the interventional and intraoperative MR imaging suite can be a safe and effective environment.     

Intraoperative and interventional MRI: Recommendations for a safe environment

In this paper we report on current experience and review magnetic resonance safety protocols and literature in order to define practices surrounding MRI‐guided interventional and surgical procedures. Direct experience, the American College of Radiology White paper on MR Safety, and various other sources are summarized. Additional recommendations for interventional and surgical MRI‐guided procedures cover suite location/layout, accessibility, safety policy, personnel training, and MRI compatibility issues. Further information is freely available for sites to establish practices to minimize risk and ensure safety. Interventional and intraoperative MRI is emerging from its infancy, with twelve years since the advent of the field and well over 10,000 cases collectively performed. Thus, users of interventional and intraoperative MRI should adapt guidelines utilizing universal standards and terminology and establish a site‐specific policy. With policy enforcement and proper training, the interventional and intraoperative MR imaging suite can be a safe and effective environment.     

OSHA's voluntary protection programs. The benefits to occupational health nurses and their companies

The Voluntary Protection Programs (VPP) consist of three different programs: Star, Merit, and Demonstration. Each is designed with different criteria to allow the opportunity for a wide range of safety and health programs to be recognized. To be accepted into the Star program it is necessary to have statistics that indicate the program is effective and to have the following six elements incorporated into a comprehensive safety and health program: management commitment; established methods of worksite analysis; established methods of hazard prevention and control; quality safety and health training; employee participation; and annual self evaluation. Because occupational health nurses have daily experience and formal training in hazard prevention and control, safety and health training, and employee health, they are invaluable resources in the VPP application process and in the maintenance of Star level protection. Decreased workers' compensation costs, decreased injury rates, and development of a positive attitude toward OSHA are benefits of the VPP for management, employees, and OSHA.     

Radiation protection for nurses. Regulations and guidelines.

Rules and regulations of federal agencies and state radiation protection programs provide the bases for hospital policy regarding radiation safety for nurses. Nursing administrators should work with the radiation safety officer at their institutions to ensure that radiation exposures to staff nurses will be as low as reasonably achievable and that special consideration will be given to pregnant nurses. Nurses' fears about their exposure to radiation can be greatly reduced through education.     

Experimental studies of the thermal effects associated with radiation force imaging of soft tissue

Many groups are studying acoustic radiation force-based imaging modalities to determine the mechanical properties of tissue. Acoustic Radiation Force Impulse (ARFI) imaging is one of these modalities that uses standard diagnostic ultrasound scanners to generate localized, impulsive, acoustic radiation force in tissue. This radiation force generates tissue displacements that are tracked using conventional correlation-based ultrasound methods. The dynamic response of tissue to this impulsive radiation force provides information about the mechanical properties of the tissue. The generation of micron-scale displacements using acoustic radiation force in tissue requires the use of high-intensity acoustic beams, and the soft tissue heating associated with these high-intensity beams must be evaluated to ensure safety when performing ARFI imaging in vivo. Experimental studies using thermocouples have validated Finite Element Method (FEM) models that simulate the heating of soft tissue during ARFI imaging. Spatial maps of heating measured with the thermocouples are in good agreement with FEM model predictions, with cooling time constants measured and modeled to be on the order of several seconds. Transducer heating during ARFI imaging has been measured to be less than 1 degrees C for current clinical implementations. These validated FEM models can now be used to simulate soft tissue heating associated with different transducers, beam spacing, focal configurations and thermal material properties. These experiments confirm that ARFI imaging of soft tissue is safe, although thermal response must be monitored when developing ARFI beam sequences for specific tissue types and organsystems.     

Simulator training to minimize ionizing radiation exposure in the catheterization laboratory

To learn about radiation and how to lower it. Patients and operators are routinely exposed to high doses of ionizing radiation during catheterization procedures. This increased exposure to ionizing radiation is partially due to a lack of awareness to the effects of ionizing radiation, and lack of knowledge on the distribution and behavior of scattered radiation. A simulator, which incorporates data on scattered ionizing radiation, was built based on multiple phantom measurements and used for teaching radiation safety. The validity of the simulator was confirmed in three catheterization laboratories and tested by 20 interventional cardiologists. All evaluators were tested by an objective knowledge examination before, immediately following, and 12 weeks after simulator-based learning and training. A subjective Likert questionnaire on satisfaction with simulation-based learning and training was also completed. The 20 evaluators learned and retained the knowledge that they gained from using the simulator: the average scores of the knowledge examination pre-simulator training was 54?±?15% (mean?±?standard deviation), and this score significantly increased after training to 94?±?10% (p?<?0.001). The evaluators also reported high levels of satisfaction following simulation-based learning and training according to the results of the subjective Likert questionnaire. Simulators can be used to train cardiology staff and fellows and to further educate experienced personnel on radiation safety. As a result of simulator training, the operator gains knowledge, which can then be applied in the catheterization laboratory in order to reduce radiation doses to the patient and to the operator, thereby improving the safety of the intervention.     

Eliminating the stigma: A systematic review of the health effects of low-dose radiation within the diagnostic imaging department and its implications for the future of medical radiation

BackgroundLow-dose radiation exposure to Canadians is exponentially increasing due to the influx of diagnostic imaging and medical procedures that utilize radiation. Despite the use of medical radiation since 1896, the standardized acceptable dose for the Canadian public is still debated. The current annual dose limit for the public is set at 1 millisievert (mSv). This set dose limit intrinsically restricts the use of medical radiation for diagnosis due to concerns of public health.MethodsThis systematic review is in the form of a retrospective meta-analysis of previous experimental studies and observational reviews of low-dose radiation health effects. A database search using PubMed and Medscape identified 1,296 articles using the terms “low-dose radiation”, “radiation hormesis”, “radiation safety”, “dose exposure”, and “medical radiation”. Full text articles were excluded for the following reasons: radiation dose level not <100mSv, results of radiation effects not included, or no inclusion of biologic effects on living tissue. After screening, 15 studies were selected for inclusion.ResultsThe concerns of radiation exposure are based on epidemiological and experimental studies that have indicated that high-dose ionizing radiation has toxic effects and increases cancer risk. In contrast, low-dose radiation has experimentally demonstrated various beneficial effects through a combination of molecular and cohort studies, randomized control trials, and observational analysis. The limitation of radiation in medical imaging is founded on the assumption that low-dose radiation health risks are a linear extrapolation of high-dose radiation.Discussion/conclusionsThrough a systematic review of research, it is proposed that the current dose-response extrapolation for radiation-related health risks cannot be linearly based on the effects at high doses. By altering this knowledge, we could effectively improve patient diagnosis and public health by redefining the restrictions of current radiation limits within diagnostic imaging.     

Perspective on radiation risk in CT imaging

Awareness of and communication about issues related to radiation dose are beneficial for patients, clinicians, and radiology departments. Initiating and facilitating discussions of the net benefit of CT by enlisting comparisons to more familiar activities, or by conveying that the anticipated radiation dose to an exam is similar to or much less than annual background levels help resolve the concerns of many patients and providers. While radiation risk estimates at the low doses associated with CT contain considerable uncertainty, we choose to err on the side of safety by assuming a small risk exists, even though the risk at these dose levels may be zero. Thus, radiologists should individualize CT scans according to patient size and diagnostic task to ensure that maximum benefit and minimum risk is achieved. However, because the magnitude of net benefit is driven by the potential benefit of a positive exam, radiation dose should not be reduced if doing so may compromise making an accurate diagnosis. The benefits and risks of CT are also highly individualized, and require consideration of many factors by patients, clinicians, and radiologists. Radiologists can assist clinicians and patients with understanding many of these factors, including test performance, potential patient benefit, and estimates of potential risk.     

Building a Magnetic Resonance Imaging Safety Culture from the Ground Up

Magnetic resonance imaging (MRI) uses a strong magnetic field to generate diagnostic images. This magnetic field has the potential to cause serious and even fatal injuries to patients undergoing scans and to personnel in the area. Ensuring awareness of MRI hazards and safety procedures through a formalized education and training program is integral in creating an MRI safety culture that protects patients and staff from harm. The aim of our project was to develop an accessible and interprofessional electronic e-module learning series to instill an MRI safety culture throughout the entire hospital. This is the first such program in Canada. A simplified e-search was conducted using key search terms “mri: safety, education, safety training.” Very few articles were found that fulfilled our needs in helping us build an MRI safety program. In concert with an e-search we reached out to similar institutions and, through informal discussions, we confirmed the lack of a formalized, transferable safety program within Canada. This led to the creation of an interprofessional working team at our institution composed of key stakeholders: educators, clinical and technical experts from radiation therapy, medical imaging, the research institute, medical radiation physics, nursing, and radiation oncology. This team collaborated on the development of three education modules tailored for specific audiences based on classification as Non-MR Personnel, Level 1 MR Personnel, or Level 2 MR Personnel as defined by the American College of Radiology guidelines. All modules were 10 to 20 minutes in length with interactive engagement activities throughout as well as a final summative evaluation to test for comprehension. Knowledge of the existence of the MRI unit is only one facet of creating an MRI safety culture. By increasing the awareness of the hazards of MRI to all personnel throughout the hospital, the risk of harm to patients and staff may be decreased.     

Health Literacy and Patient Preparation in Radiology

Health literacy is the capacity of an individual to obtain, process, and understand basic health information and services needed to make appropriate health decisions. Unfortunately, more than half of Canadians cannot adequately navigate the health care system because they have limited health literacy. Patients with low health literacy may have limited reading abilities and poorer comprehension of written preparation documents. An important consideration in the radiation sciences for these patients is the ability to follow preparation requirements for diagnostic imaging procedures. It has been suggested that patients with limited health literacy are often less prepared for diagnostic examinations, and as a result, tend to have examinations of poorer diagnostic quality. Medical radiation technologists play an important role in educating patients regarding medical imaging examinations and helping them to properly prepare for these procedures. The purpose of this article is to define health literacy, provide some practical strategies to help medical radiation technologists identify patients with limited health literacy, and how to address limited health literacy issues to improve the quality of diagnostic imaging examinations.     

The Challenge of Positional Car Seat Testing in Healthy Near-term Neonates

The American Academy of Pediatrics Committee on Injury and Poison Prevention recommends that hospitals develop policies that include a period of observation for any infant less than 37 weeks' gestation in an infant car safety seat before hospital discharge to monitor for apnea, bradycardia, or oxygen desaturation. Development of policy guidelines presents a challenge to health care providers on many levels. What evidence is the basis for this recommendation of the American Academy of Pediatrics? Does this recommendation include healthy near-term infants in level I nurseries? How should such policies be produced and implemented? What training and education will be necessary? How much will this cost? This article reviews the evidence for clinical practice and shares clinical experiences in policy development, education, and cost containment.     

Hospital in the home: nurse safety--exposure to risk and evaluation of organisational policy.

This pilot study describes the findings of a survey of the perception of threat versus the actual threat reported by 35 Victorian Hospital In The Home (HITH) nurses. The provision of HITH care has increased significantly in Victoria during the past five years with 42 programs in operation. To explore the effects of this increase in HITH care provision on nurse safety, we investigated how nurses perceive the level of threat in their practice and how they describe potential versus actual threats that they have encountered. The study also examined the level of support and training concerning safety provided to HITH nurses by conducting a review of the relevant educational, policy and procedure documentation of HITH programs. The results show considerable variation between what nurses considered as being a potentially threatening situation versus an actual incident. No significant relationships were detected between the level of threat reported by the nurses and their age or professional experience. We also found that there were important staff safety policy and procedural omissions in some HITH programs. In some cases these omissions were of a degree that may expose the employer to claims of negligence should a serious incident occur.     

Developing a Moderate Sedation Policy: Essential Elements and Evidence-Based Considerations

Developing an institutional policy for moderate sedation is a multidisciplinary effort that should involve close collaboration among clinicians, administrators, and risk managers. A variety of health care providers administer moderate sedation. Sedation policy should address essential elements, such as clinician training and credentialing, equipment, preprocedure evaluation, periprocedure patient monitoring, postprocedure observation and discharge, pharmaceutical agents, and outcomes assessment. Sedation policy should comply with local, state, and national guidelines and standards. Furthermore, sedation policy should be evidence based to incorporate the latest information about best practices and outcomes. Advances in pharmacology, monitoring, medication delivery systems, and simulation training can help improve quality of care and patient safety in the administration of moderate sedation.     

Survey of current practice in clinical transvaginal ultrasound scanning in the UK

During transvaginal ultrasound scanning, the fetus and other sensitive tissues are placed close to the transducer. Heating of these tissues occurs by direct conduction from the transducer and by absorption of ultrasound in the tissue. The extent of any heating will depend on the equipment and settings used, the duration of the scan, imaging modes and other aspects of scanning practice. To ensure that scans are performed with minimum risk, staff should have an appropriate knowledge of safety and follow guidelines issued by professional bodies.An online survey aiming to document current practice in transvaginal ultrasound in the UK was created and distributed to individuals performing this type of scanning. The survey posed questions about the respondents, the departments where scans were performed, the equipment used, knowledge of ultrasound safety, scanning practice and the frequency, duration and mode of transvaginal ultrasound scans for gynaecology, obstetrics and fertility applications. In all, 294 responses were obtained, mostly from sonographers (94%). From the analysis of the responses, it was clear that there was a good understanding of the general meaning of thermal and mechanical index and high awareness of guidelines issued by professional bodies. However, 40% of respondents stated that they rarely or never monitor Thermal or Mechanical indices during scanning. Scanning practice was consistent in terms of the duration of scans, scan protocols followed and use of imaging modes. The results highlight the importance of continued ultrasound safety training and promotion of safety guidelines to users.     

Cardiopulmonary resuscitation policies in northwest England hospices: a telephone survey

DESIGN: A survey into existence of resuscitation policies in hospices in Northwest England. METHODS: All 25 hospices in the region were contacted. The clinical services manager or equivalent person was interviewed by telephone by means of a structured questionnaire. RESULTS: The telephone survey had a 96% response rate. Sixteen (67%) hospices did not have a resuscitation policy although 50% of this group were developing a policy. Only eight (33%) hospices had a formal policy at the time of interview. Twenty hospices (83%) provided staff with annual training in basic resuscitation. One hospice (4%) discussed cardiopulmonary resuscitation (CPR) with all patients admitted, whereas six (25%) discussed CPR only if the patient raised the topic. Five hospices (21%) would advise the patients that they should be cared for in an acute hospital, as no resuscitation would be provided. Only four hospices (17%) had written information on resuscitation. DISCUSSION: There was significant variation in the production and adherence to guidelines on resuscitation, with some patients being denied access to specialist palliative care units, as they would wish resuscitation. Much anxiety and confusion regarding this topic existed and staff clearly required further education and guidance in order to develop policies within their units and to provide standard treatment within all specialist palliative care units.     

Neuro-oncology update: radiation safety and nursing care during interstitial brachytherapy

Radiation control and safety are major considerations for nursing personnel during the care of patients receiving brachytherapy. Since the theory and practice of radiation applications are not part of the routine curriculum of nursing programs, the education of nurses and other health care professionals in radiation safety procedures is important. Regulatory agencies recommend that an annual safety course be given to all persons frequenting, using, or associated with patients containing radioactive materials. This article presents pertinent aspects of the principles and procedures of radiation safety, the role of personnel dose-monitoring devices, and the value of additional radiation control features, such as a lead cubicle, during interstitial brain implants. One institution's protocol and procedures for the care of high-intensity iridium-192 brain implants are discussed. Preoperative teaching guidelines and nursing interventions included in the protocol focus on radiation control principles.     

Sustainability in the cardiac cath lab

Use of radiation for medical examinations and test is the largest manmade source of radiation exposure. Interventional procedures are only 2% of all radiological procedures, but contribute to about 20% of the total collective dose per head per year. On average, a left ventriculography and coronary angiography corresponds to a radiation exposure for the patient of about 300, a coronary stent to 1,000, a peripheral artery intervention to 1,500 to 2,500, and a cardiac radiofrequency ablation to 900-1,500 chest x-rays. Invasive cardiology procedures increased tenfold in the last ten years and growth in the field has been accompanied by concern for the safety of the staff. Interventional cardiologists have an exposure per-head per year two- to three times higher than that of radiologists, with an annual exposure equivalent to around 250 chest x-rays per head. A reduction of occupational doses by a factor of ten can be achieved simply by and intensive training program. The awareness of radiation effects may be suboptimal in the medical community. It is recommended by professional guidelines and reinforced by the European law that the responsibility of all physicians is to minimize the radiation injury hazard to their patients, to their professional staff and to themselves. In response to the article by Rigatelli et al. Impact of intracardiac echocardiography on radiation exposure during adult congenital heart disease catherer-based interventions (DOI: ).     

Inviting injury

PPE equals one thing personal safety. Employers must ensure that responders are provided with applicable PPE and taught how to use it for the incidents and environments they may encounter. Responders who fail to wear PPE or wear it inappropriately invite injury. Employers should not assume that responders know how or even when to use certain PPE--regular in-service training should be provided. As a responder, you have a responsibility to always undertake safe actions. If you follow this monthly column, you have no doubt heard me say repeatedly that nothing, absolutely nothing, supercedes safety. You are not an expendable resource. Wear your PPE and, most important, wear it the right way.     

Improving Efficiency in the Nuclear Cardiology Laboratory: The Role of Stress-Only Imaging Coupled with Faster Acquisition Protocols and New Stressor Agents

Laboratory efficiency is an important benchmark to achieve whether imaging is hospital-based or in the private practice setting. The stressor and imaging protocols used and the camera systems available for imaging all play a pivotal role toward this end. A same-day low-dose rest/high-dose stress imaging protocol has been widely adopted in nuclear cardiology laboratories. However, recent studies indicate that rest imaging may be unnecessary in patients with a normal initial stress single photon emission CT (SPECT) study. Appropriate elimination of rest imaging would decrease costs, streamline patient evaluations, and significantly reduce radiation exposure. Several recent studies have validated the safety of stress-only imaging in patients who have an initially normal perfusion study. Combined with new pharmacologic stressor agents and camera systems that can complete imaging within minutes, laboratory efficiency and patient satisfaction should improve considerably. The following article will review these currently available advances in SPECT imaging.