1
Q
Profession definition?
A
specialized knowledge + intensive academic preparation
2
Q
Professionalism definition?
A
Conduct, aims, or qualities that characterize or mark a profession or a professional person.
3
Q
Several fundamental principles and physician responsibilities, that apply to all professionals in medicine have been specified in a Physician Charter, supported by?
A
American Board of Internal Medicine (ABIM).
4
Q
In the physician charter by ABIM, how many professional responsibilities and how many fundamental principles mentioned?
A
- 10 professional responsibilities
- 3 fundamental principles of medical professionalism
5
Q
What are the 3 fundamental principles of medical professionalism stated by the ABIM in the physician charter?
A
1- Patient welfare (patient interest, regardless of market forces).
2- Patient autonomy (let pt decide their care).
3- Social justice (fair distribution of resources).
6
Q
what are the 10 professional responsibilities of medical professionalism stated by the physician charter?
A
1- Competence: basic knowledge needed to be a doctor + appropriate licencing.
2- Honesty: must be honest with pts, disclose errors when occur.
3- Confidentiality: protecting pts records.
4- Proper MD-pt relationship: e.g. not taking sexual/financial advantage of pts.
5- Quality of care: work collaboratively with other professionals.
6- Access to care: care available to all people.
7- Just distribution of finite resources: cost-effective (e.g. cancel unnecessary tests).
8- Scientific knowledge: (promote research)
9- conflicts of interest: (avoid personal gain)
10- professional responsibilities: ( work collaboratively for pt’s best interest, and remediation and discipline of those who fails to do so).
7
Q
ABIM professional responsibilities largely overlap with which organization’s code of ethics Bylaws?
A
ACR.
- AmericanCollege of Radiology (ACR) Code of Ethics Bylaws largely overlaps with ABIM professional responsibilities.
8
Q
what are the major principles of ACR Code of Ethics?
A
1- Professional limitations: (seek help if you do not know the answer).
2- Report illegal conduct: to appropriate governing body.
3- Report signature: only sign your own reports.
4- Participate in quality activities: e.g.QA.
5- Self-referral: recommending unnecessary exams for personal financial gain.
6- Harassment: avoid unfair discriminatory behavior.
7- Undue influence: ensure that your employer utilizes the standard of care exams/treatments.
8- High quality care: provide optimal care, not below acceptable standards
9- Misleading billing: unnecessary fees to pts.
10- Expert testimony: give honest medical opinion.
11- Research integrity: avoid research misconduct or data manipulation.
12- Plagiarism: of other’s work as yours.
13- Misleading publicizing: avoid social media/forum misleading or deceptive manners/behaviors.
9
Q
Quality definition?
A
value + excellence
10
Q
Ultimate goal of quality in healthcare?
A
Decreasing unnecessary variation, both in processes and outcomes = standard procedures + standard outcomes.
11
Q
Major components of Quality in healthcare?
A
1- provide excellent + consistent care.
2- Organization must monitor its doctors to ensure consistent quality.
3- increase likelihood of desired health outcome for your patient
AS WELL AS:
- satisfying the patient.
- using the most recent professional knowledge/standards based on evidence.
12
Q
The ultimate arbiter of “quality” is the?
A
PATIENT
13
Q
Quality control (QC)
A
Most basic level of quality. Things that you can fix yourself right on the spot at the workstation: Fixing your report before signing. Ensure that tech sent all sequences, ensure that radiation/contrast dose are reported.. etc.
14
Q
Quality assurance (QA)
A
QA is performed by the organization. Basically your employers assumes that the system you currently use is PERFECT, and their job is to ensure you are following all guidelines as instructed by them, or receive punitive actions. E.g Enforcing all residents to use radiology templates.
15
Q
Quality improvement (QI)
A
QI is opposite of QA. It assumes all systems are NOT perfect and seek continuous quality improvement(CQI).
E.g. continuous improvement of radiology report using standardized templates.
16
Q
Difference between QC/QA/QI
A
1- QC is the most basic of all, and simply means your initiative reaction to simple errors at the workstation, and attempt to fix them on the spot.
2- QA is more comprehensive than QC (QC is considered a part of QA). QA is done at an organizational level. Assumes the current system is perfect and you must follow it or receive punitive action.
3- QI is the opposite of QA. QI assumes the current system is NOT perfect and there is always room for improvement. It does not seek punitive action against violators but rather coaching and guidance.
17
Q
what’s “quality department” and what’s the opposite of it?
A
- Quality department: only certain staff are responsible for QC/QA/QI.
- the opposite of quality department is when: front-line staff.
- quality has come to be recognized as the responsibility of everyone in the organization—especially front-line staff.
18
Q
Three major IOM ( Institute of Medicine) Reports have been released in which years? and what’s the highlight of each year?
A
- 2000 Report: To Err is Human
- 2001 Report: Crossing the Quality Chasm
- 2015 Report: Improving Diagnosis in Health Care
19
Q
- 2000 IOM Report: To Err is Human. This report stated that:
A
1- There is 44,000 and 98,000 in-hospital deaths per year were attributable to medical errors, which can cost $17-29 billions
2- Major causes is:
- decentralized (nonsystem) nature of healthcare: various designs to medical equipment by vendors.
- Organization and third party’s lack of focus/financial investment to detect and fix errors.
20
Q
- 2001 Report: Crossing the Quality Chasm report stated that:
A
everyone should commit to reduce the burden of illness, and improve the health of Americans, via 6 steps:
1- safe: to pt.
2- effective: avoid underuse or overuse.
3- Pt-centered: ensure pt values guide all clinical decisions.
4- Timely: reducing waits.
5- Efficient: avoiding waste.
6- Equitable: avoid discrimination.
21
Q
- 2015 Report: Improving Diagnosis in Health Care, stated that
A
1- Redefine “medical errors” to encompass patient being the center of attention, and include communication as part of the definition.
2- Error is now defined as: the failure to (a) establish an accurate diagnosis or (b) communicate it to the patient.”
3- It proposed that: Americans will likely experience a meaningful diagnostic error in their lifetimes.
4- Similar to the 2000 IOM report, this report called for objective, nonpunitive efforts to understand error and
to improve systems and processes accordingly.
5- The report authors made “8” specific recommendations for improvement in the diagnostic processes: 1- teamwork (rad-path are part of the medical team). 2- education. 3- IT support. 4- error detection. 5- Redesign payment (get rid of fee-for-service model). 6-Error reporting system. 7- Reduce diagnostic errors 8- dedicated research funding.
22
Q
6 Core Competencies of the ABMS and ACGME that all physicians should attain:
A
1- Practice-based Improvement: ability to investigate patient care.
2- Patient Care: provide compassionate care.
3- Systems-based Practice: coordinate care across different specialties/medical centers where pt received care.
4- Medical Knowledge: demonstrate medical knowledge.
5- Communication Skills: with pts/families.
6- Professionalism: adhering to ethical principles.
23
Q
Human Factors Engineering, examples?
A
When medical equipment design fails us leading to medical errors: drop-down menu, different CPR pads design, different epipen design (hindering use or allowing incorrect doses during time of emergency).
24
Q
Communication two components?
A
1- conveyance: you explain your finding.
2- convergence: you allow the clinicians to inquire and confirm if they understood.
25
High Reliability Organization (HRO) maintain their resilience to medical errors through two mechanisms
1- Anticipation:
___a: Preoccupation with failure: always assumes there is a problem.
___b: Reluctance to simplify: when a problem is found, do not accept a simple explanation.
___c: Sensitivity to operations: leaders understanding of the messy reality of what's actually happening.
2- Containment:
___a: Commitment to resilience: realize errors are common.
___b: Deference to expertise: leaders allow experts to run the investigations.
26
What's the three levels of human error?
SRK:
1- Skill: Requires no focus or decision making. e.g. driving, tying shoelace.
2- Rule: Requires some focus and attention. e.g. making decision during a familiar situation.
3- Knowledge: requires high level of attention. e.g. learning new modality or unfamiliar procedure.
27
How to fix Skill-based errors?
Fix by: behavior- shaping constraints (e.g. microwave won't start with the door open). in medicine: EMR won't let you order medication that pt is allergic to and will flag your order.
Do not attempt to fix skill-based errors with additional training. If an MD placed an order of 10mg of a drug by error instead of 10ug, it would be useless to send him/her to an additional training on metrics conversion, as he/she knew it, and error was part of skill-based, not knowledge based.
If however a nurse did the same mistake because of a math error in dilution/unit conversion, because she forgot how to do it, then you send them to additional training to refresh that.
28
How to fix Rule-based or knowledge-based errors?
increased supervision, additional training and coaching, deliberate practice, and intelligent decision support.
29
“culture of safety” has been observed mainly in what type of clinical setting?
Answer: HRO.
The concept of safety culture originated in studies of high reliability organizations.
30
How can an organization implement a culture of safety?
Acknowledge the existence of high risk nature, and provide a blame-free environment to detect and fix them.
31
What can hinder implementation of culture of safety?
1- “culture of low expectations:” poor teamwork and communication so staff would assume low expectations among each other.
2- the presence of steep authority gradients: fear of superiors to report errors.
32
What's the three levels of just culture? and Who proposed it?
Proposed by David Marx.
1- Human Error: honest mistake (mistake due to large volume of patients, or poor EMR system, poor hours).
2- At risk behavior: taking shortcuts to speed up your workflow by ignoring minor steps (labeling needle).
3- Reckless behavior: taking major shortcuts that is severely dangerous to patients by ignoring major steps (e.g. not obtaining a consent prior to procedure).
33
How to deal with Human Error, at risk behavior, and reckless behavior?
1- human error: console them.
2- at risk behavior: coach them.
3- reckless behavior: Punish/Sanction
34
Who is the "second victim"?
The radiologist, who is traumatized by an error or adverse patient event.
35
Standardization is the ultimate solution for human factor engineering. Give three examples:
1- standardize equipment to not allow errors to happen (different hub sizes for IV vs intrathecal meds).
2- Establishing an agreed- upon, standardized approach
3- Checklist utilization by staff to reduce errors.
36
QI comes in two flavors: (a)small-scale daily management systems AND (b)large-scale projects. What are 3 examples of small-scale QI stuff?
These are things done on daily basis:
1- Daily Management Systems (DMS): daily meetings of "leaders" to engage with "staff" to solve problems on a continuous basis.
2- Tiered Huddles: discuss current and future concerns of a team/unit, and track everything on "visibility board" (often simply an organized white board).
3- Daily Readiness Assessment: make sure for every working day that you have enough: staff, equipment, and supplies to meet demand of seeing patients assigned for the day.
Additional stuff:
(a)Problem Management on daily basis during huddles,
(b)Accountability Cycle of owner of idea/concern,
(c)Regular Follow-up of how much progress done for each concern/problem, and
(d)Frequent Visits of leaders to the Workplace to ensure things are done right.
37
QI comes in two flavors: small-scale projects and large-scale projects. discuss in details 10 steps of establishing a large-scale QI project?
1-Identifying a Problem
2-Forming a Team: 4 team members:
___a- Project Sponsor (organizational oversight and support)
___b- Project Leader: (assemble the team, manage the project)
___c- Project Participants: (front line volunteer staff)
___d- Project Coach: (guide the leader, liaison b/w sponsor and leader).
3-Assessing Current Performance
4-Measuring Performance: (e.g. outcome, cost via annotated run chart).
5-Establishing a Specific Goal: SMART ( "specific, measurable, achievable, relevant, and time-bound.")
6-Identifying Causes of Problems (fishbone diagram)
7-Prioritizing Problem-solving Efforts (Pareto chart)
8-Developing Solutions through Iterative Testing (PDSA: = Plan, Do, Study, Act)
9-Sustaining the Improvement (High-reliability Solutions)
10-QI Project Management (execute projects effectively)
38
In QI large-scale projects, discuss types of charts used in Measuring Performance?
1- annotated run chart: shows "mean" and "goal" of a target as a function of "time, e.g. days". Your job is to see on which day the mean will hit the goal (target value).
39
in large-scale QI projects, "Establishing a Specific Goal" is utilizes the nemonic "SMART," which stands for?
- SMART= goal should be "specific, measurable, achievable, relevant, and time-bound." (e.g. our goal is to decrease mean daily examination completion time from 120 minutes to 30 minutes by July 1, 2018).
40
in large-scale QI projects, "Identifying Causes of Problems" utilizes what type of chart?
- fishbone diagram (Cause-and-effect diagram)
41
in large-scale QI projects, "Prioritizing Problem-solving Efforts" utilizes what type of chart?
- The Pareto chart/principle (causes that occur most frequently, aka 80/20 rule) = problem types and their frequency.
- Next, prioritize problems accordingly (target major problems first).
42
What's the 80/20 rule?
- The Pareto chart/principle = 80% of consequences come from 20% of the causes, so as a project leader in a large-scale QI project, you should target these 20% causes first, aiming for 80% improvement.
43
in large-scale QI projects, "Developing Solutions through Iterative Testing" utilizes the nemonic "PDSA," which stands for?
- PDSA = Plan, Do, Study, Act:
1- Plan: plan to test that hypothesis
2- Do: testing the hypothesis
3- Study: analyzing the data (studying the results),
4- Act: drawing actionable conclusions and determining next steps (acting accordingly).
44
how many PDSA should be run to ensure most effective QI improvement in a large-scale project? Single PDSA or multiple simultaneous PDSA is better?
multiple sequential or simultaneous is better than single PDSA, also with multiple revisions, and
45
in large-scale QI projects, "Sustaining the Improvement" requires what to ensure no relapse to initial state?
Answer: High-reliability Solutions. How?
1- changes to infrastructure: best method to prevent relapse of new QI implementation.
2- standardization of procedures: second best.
3- education and feedback: worst, weakest method.
46
What's the definition of QI "project management" required in large-scale projects?
Project management is the application of knowledge, skills, and techniques to execute projects effectively and efficiently. How?
1- task management.
2- Progress tracking.
3- conducting effective meetings.
47
Patient Identifiers, how many and list some examples?
2 is minimum. List: patient name, assigned identification number, telephone number, or other person-specific identifier (e.g., date
of birth, government-issued photo identification, and last four digits of the social security number)
48
prior to sedation, one must evaluate?
PO intake, recent URI, cardiac status, baseline vital signs, level of consciousness, pulse oximetry, capnography, ECG.
49
1- Reduce anxiety,
2- responds to verbal commands,
3- impaired cognitive function and coordination
4- intact ventilatory and cardiovascular functions
Minimal Sedation (Anxiolysis).
50
1- minimally depressed level of consciousness.
2- maintain protective reflexes
3- retains patent airway
4- aroused by physical or verbal stimulation.
Moderate Sedation/Analgesia.
51
1- cannot be easily aroused
2- responds purposefully after repeated or painful stimulation.
3- lose ability to maintain a patent airway.
4- Cardiovascular function is usually maintained.
Deep Sedation/Analgesia.
52
1-Minimal vs 2-moderate vs 3-deep sedation. Each is Defined as what?
1- Reduce anxiety,
2- minimally depressed level of consciousness.
3- cannot be easily aroused
53
1-Minimal vs 2-moderate vs 3-deep sedation. Each respond to what?
1- responds to verbal commands,
2- aroused by physical or verbal stimulation.
3- responds purposefully after repeated or painful stimulation.
54
1-Minimal vs 2-moderate vs 3-deep sedation. Each lose what? and Maintain what?
1- lose cognitive function and coordination, but maintain ventilation and CV function.
2- lose (minimally) level of consciousness, but maintain patent airways/protective reflexes/CV function.
3- lose ability to maintain airway but maintain CV function.
55
General anesthesia? define! what does patient lose? Can they respond to any stimuli?
Controlled state of unconsciousness in which there is a complete loss of protective reflexes, cannot maintain airway, and cannot respond to painful stimulation.
56
which sedation must be monitored at all times?
all sedated patients require monitoring regardless of the intended level of sedation.
57
ASA 1 to 6 examples?
1- ASA-I: You are at your parents home: normal healthy person.
2- ASA-II: You go to college (get wild): you smoke, drink, you get pregnant, you get fat, and from smoking/cheeseburger you get DM/HTN/mild lung disease.
3- ASA-III: You get married(more smoking and more cheeseburgers): poorly controlled DM or HTN, COPD, morbid obesity, liver/kidney/heart disease, however is on dialysis and has a pacemaker.
4- ASA-IV: You get divorced (no one to take you to cardiologist or dialysis appts): severely low %EF, ESRD not on dialysis,
5- ASA-V: You are dying from sitting home all day: something ruptured or bleed and you need surgery now (DVT->bowel ischemia/ ruptured AAA/ brain bleed).
6- ASA-VI: You are dead (they could not save you): confirmed brain dead.
58
ASA definitions?
• Class I - A normal healthy patient
• Class II - A patient with mild systemic disease
• Class III - A patient with severe systemic
disease
• Class IV - A patient with severe systemic disease that is a constant threat to life
• Class V - A moribund patient who is not
expected to survive without the operation
• Class VI - A declared brain-dead patient whose
organs are being removed for donor purposes
59
which ASA class may require anesthesia, and which one requires
- Classes III and IV : consult with anesthesiology or the performance of sedation by an anesthesiologist or anesthetist.
- Class V should not be sedated by non-anesthesiologists.
60
Consent can also be documented by a note in the patient’s medical record, by a recording on videotape, or by another similar permanent modality. . True or false?
True
61
Other than the patient, or the patient's representative, whom else must sign the consent form?
The physician or other healthcare provider performing the procedure.
62
list 6 elements of informed consent.
1) the purpose and nature of the intended procedure,
2) the method by which the procedure will be performed,
3) likely risks, complications, and expected benefits,
4) risks of not proceeding,
5) any reasonable alternatives to the proposed procedure
6) the right to decline the proposed procedure.
63
Only exception for performing a consent?
Only if delay in treatment would jeopardize the health of a patient who is unable to provide informed consent (e.g., an unconscious trauma patient for whom family has not yet been identified).
64
How to consent an incapacitated patient?
The patient’s appointed healthcare representative, legal guardian, or appropriate family member.
Exception is that a physician can proceed with the procedure without consent: “to prevent serious disability or death or to alleviate great pain or suffering.”
65
At what age, States and courts have never allowed children to make medical decisions and exercise self-determination,
younger than 12 year old.
66
what's the youngest age to make your own legal decisions?
Age 12-18, especially if you are:
1- pregnant, parent, or military.
2- shows signs of mental maturity.
3- STD, HIV, or substance abuse.
67
What's the universal protocol?
3 steps:
1- conducting a preprocedure verification (equipment, patient identifiers, and verify procedure expectations).
2- marking the procedure site.
3- performing a preprocedure time out (you, anesthesia providers, the circulating nurse, the operating room technician, and other active participants).
68
Can medical student mark the procedure site?
YES! In limited circumstances, site marking may
be delegated to medical residents, physician assistants (PAs), or advanced practice registered nurses (APRNs), but ultimately the licensed independent practitioner is accountable for the procedure, even when delegating site marking.
69
Three components of time out?
1- correct patient identity (at least 2),
2- correct site,
3- correct procedure to be done.
70
Can the patient be sedated or awake for time out?
it is okay if patient is sedated prior to time out.
71
Do you have to document timeout?
Yes, you must! Documentation of the time out should be performed according to the organization’s policy.
72
When alcohol based hand-washing is not appropriate?
1- hand is visibly dirty
2- Clostridium difficile,
3- Norovirus,
4- Bacillus anthracis.
73
how many seconds you should wash your hands using soap and water vs alcohol based gel?
- Soap and water: 15 seconds
- alcohol based gel: 20 seconds.
74
Root cause analysis (RCA) is meant to detect what type of errors?
1- active errors (errors occurring at the point of interface between humans and a complex system) and
2- latent conditions (the hidden problems within healthcare systems that increase the likelihood of an adverse event).
75
What's the first step of RCA?
RCAs should generally begin with data collection to create an objective narrative of the event based on a review of the medical record and interviews with people involved.
76
RCA usually detect single or multiple causes to a problem?
It should be recognized that serious adverse events are almost never the result of a single cause, and often are associated with numerous contributing factors.
77
MRI ZONES
- Zone I: Access is unrestricted.
- Zone II: greet patients, obtain patient histories, and screen patients for MR safety issues.
- LOCK: between zones 2 and 3.
- Zone III: (scanner control room): only for screened patients and possibly family members, nurses, etc if their presnece is necessary for obtaining MRI.
- Zone IV: MR magnet.
78
What to do if patient had an emergency in zone 4? Start CPR first or move patient our first?
Start CPR WHILE getting pt out of zone 4 is the best answer.
MR trained and certified personnel should begin basic life support or CPR if required, while urgently moving the patient from Zone IV to a magnetically safe location.
79
Types of MRI safety levels for medical devices
- “MR Safe,”
- “MR Unsafe.”
- “MR Conditional”
80
how many Gauss should be the handheld magnet?
1000G.
All MR sites should have a handheld magnet (≥ 1000 Gauss) or handheld ferromagnetic detection device, which allows for testing of external objects and some superficial internal implants.
81
what's the 5G line?
The 5 Gauss line is the point at which the magnetic field begins to affect electromagnetic devices such as pacemakers.
82
Which two medical devices must be MR scanned with caution?
1- aneurysm clips: can rotate and safety must be evaluated based on manufacturer documentations (even if pt was already MR scanned with this clip).
2- cardiac implantable devices: lead heating, ventricular arrhythmia, or failure to pace. Radiology, cardiology, and crash cart must be present during scan.
83
When FDA-labeled MR Conditional pacemakers became available in the USA?
February 2011.
84
MRI and pregnant patient?
MRI is safe as long as it is an urgent scan. Gadolinium is not.
85
MRI and pregnant tech?
MRI is safe as long as tech is not present in Zone IV while data acquisition (gradient are ON).
86
Why MRI can cause burns?
radiofrequency (RF) fields, or phyical contact with MR bore.
87
How can an MRI produce current within patient?
RF fields can also induce currents within the body, particularly when a “closed loop” is formed.
88
what can cause skin burns to pt during MRI?
1- e.g. inner thigh or pannus skin touching in obese patients -> burns. Fix by using padding.
2- clothes with metal, dermal patches with aluminum, and large tattoos.
89
how cold and how large the liquid helium around the MRI magnet?
2000Liters, cooled to 4°K.
90
what's Quenching?
release of He from the superconducting MR coil -> heating -> lose magnetism -> shutdown.
91
Major side effect of Quenching failure leading to He leak inside Zone IV?
Asphyxiation, followed by positive pressure in Zone IV, and fog. So you must evacuate Zone IV before quenching.
92
All iodinated contrast media are derived from
triiodinated benzene rings (monomeric), or dimeric (two joined tri-iodinated benzene rings).
93
Iodinated contrast media can be classified as
ionic or nonionic and monomeric or dimeric.
1- ionic monomeric = 4x human plasma osmolality, (High-osmolality contrast media (HOCM)) = highest rate of contrast reaction, and if given intrathecally can cause seizures and death.
2- Nonionic monomeric = 2x human plasma osmolality = Low-osmolality, nonionic contrast media (LOCM) = most commonly used for VENOUS injection = minimal side effect/reactions.
3- Nonionic dimers = 1x human plasma osmolality = iso-osmolality, nonionic contrast media (IOCM) = most commonly used for ARTERIAL injection = least side effects and contrast reaction.
94
Nonionic contrast media are hydrophilic molecules that do not need to be conjugated with cations to be water soluble. are they dissciatable?
They do not dissociate in solution.
95
Monomeric contrast molecules contain only one tri- iodinated benzene ring, while dimeric contrast molecules contain
two joined tri-iodinated benzene rings.
96
ionic monomeric contrast media have the highest osmolality, roughly ____ times that of human serum.
four times that of human serum
97
Which iodinated contrast media associated with highest contrast adverse reaction?
ionic monomeric (high-osmolality contrast media) have higher rates of adverse reactions than are nonionic monomeric or dimeric contrast media.
98
compare Nonionic monomeric contrast media (low osmolality) to human serum
four times that of human serum.
99
Nonionic dimers have similar osmolality to that of plasma and are referred to
iso-osmolality contrast media
100
which iodinated contrast media subtype with least discomfort during arterial/venous injection
iso-osmolality contrast media
101
examples of low osmolality contrast agents?
iohexol (Omnipaque),
iopamidol (Isovue),
iopromide (Ultravist),
ioversol (Optiray),
ioxilan (Oxilan).
102
Only one iso- osmolality (non-ionic dimeric) contrast agent has been approved for use in the USA is:
iodixanol (Visipaque). ONLY one that has chemical name with "di" in it.. others do NOT.
103
Adverse contrast reactions of any type have been reported in up to how much % of patients injected with nonionic contrast material
3%
104
physiologic reaction to iodinated contrast is dose dependent or independent?
Physiologic reactions are dose related (more contrast = more problems) and thought be a direct toxic effects of the injected contrast media.
105
mechanism of allergic-like reactions is:
not understood and is NOT antigen-IgE antibody mediated (unlike penicillin allergy), and is NOT dose related.
106
allergic-like reactions to iodinated contrast is dose dependent or independent?
allergic-like reactions are: idiosyncratic and can occur from any administered volume of contrast media.
107
Mild Reactions: Signs and symptoms are
self-limited and without progression.
108
Moderate Reactions: Signs and symptoms are more pronounced and
commonly require medical management.
109
Severe Reactions: Signs and symptoms are potentially life threatening and can result in
permanent morbidity or death if not managed appropriately.
110
Describe difference between mild/moderate/severe physiologic reactions
1. Mild (ate a bad salad): Nausea, vomiting, flushing, warmth, chills, headache, anxiety, altered taste, mild hypertension, and spontaneously resolving vasovagal reaction
2. Moderate: vasovagal reaction that requires and is responsive to treatment
3. Severe: Vasovagal reaction resistant to treatment, or (hyperthyroidism like problems): arrhythmia, seizures, hypertensive crisis, pulmonary edema, cardiopulmonary arrest.
111
Describe difference between mild/moderate/severe Allergic-like reactions
1. Mild (ate big piece of wasabi): Few hives, pruritus, limited cutaneous edema, itchy/scratchy throat, nasal congestion, repetitive sneezing, stuffy nose
2. Moderate: Diffuse hives, diffuse erythema, facial edema without dyspnea, wheezing (with stable vital signs and mild/no hypoxia).
3. Severe (anaphylactic shock): Diffuse edema or facial edema with dyspnea, erythema with hypotension, laryngeal edema with stridor and/or hypoxia, wheezing (with hypoxia, severe hypotension and tachycardia), pulmonary edema, cardiopulmonary arrest.
112
what are the two symptoms that can be present in either allergic-like or physiologic reaction?
pulmonary edema and cardiopulmonary arrest can be symptoms of either severe physiologic or severe allergic-like reactions.
113
what's the most common and rarest subtypes of iodinated contrast reaction?
- Most common: physiologic, mild, and self- limiting, often consisting of warmth, metallic taste, and nausea.
- Rarest: Allergic-like reactions are much less common, encountered in < 1% of injected patients (severe allergic like is about 0.01% (1:10,000) of all injected patients).
114
how many folds of likelihood to develop iodinated contrast reaction if you had:
1- prior reaction to contrast.
2- allergies and asthma.
3- shellfish allergy
4- Gadolinium allergic like reaction.
1- prior reaction to contrast: 5 folds.
2- allergies and asthma: 2-3 folds.
3- shellfish allergy: none.
4- Gadolinium allergic like reaction: none.
115
which chronic illnesses that can be exacerbated by contrast media?
CKD, AKI, cardiac arrhythmias, CHF, myasthenia gravis, and severe hyperthyroidism.
116
What type of treatment in which iodinated contrast media is contraindicated for 4-6 weeks prior to treatment initiation?
- thyroid cancer or hyperthyroidism who are anticipating treatment with radioactive iodine (131I).
117
List 4 regimens of premedication to iodinated contrast (2 adult dosing, one rapid dose, and one pediatric dosing):
1-Standard dose: Prednisone 50 mg PO at 13, 7, 1 hours prior to exam.
2-Standard dose: Methylprednisolone (medrol) 32mg PO at 12, 1 hour prior to exam.
3-Rapid dose: hydrocortisone 200mg IV at 4, 0 hours prior to exam (minimum of 2 doses).
4- Pediatric dose: Prednisone 0.5mg/kg PO at 13, 7, 1 hours prior to exam.
All of them can receive: Diphenhydramine (Benadryl) – 50 mg PO (for pediatric: 1.25 mg/kg PO) at 1hr prior to exam.
118
A contrast reaction that occurs despite premedication is called
a “breakthrough reaction.”
119
The only proven benefit of corticosteroid premedication regimens is a reduction in the number of
mild reactions in average-risk patients.
120
There is no definite evidence that iodinated contrast premedication protects against:
moderate, severe, or life-threatening reactions, although this may be the case.
121
Side effect of corticosteroid premedication regimens:
transient hyperglycemia, infection, and peptic ulcer disease, steroid psychosis, and tumor lysis syndromes,
122
Postcontrast Acute Kidney Injury (PC-AKI) and Contrast-induced Nephropathy (CIN)
- (PC-AKI): sudden deterioration in renal function after 24 to 48 hours:
1. Sudden increase of baseline serum creatinine by 0.5 mg/dL (50%),
2. reduction in urine output to 0.5 mL/kg/h for at least 6 hours.
- (CIN): subset of PC-AKI: super rare and can be seen in severe CKD (eGFR < 30) or AKI, and manifests as a rise in serum creatinine beginning within 24 hours, peaks at 4 days, and return to baseline by 7-10 days, WITHOUT oliguria.
123
Administration of large or multiple doses of contrast media within 24 to 48 hours may also be a risk factor for:
AKI (although precise risk thresholds are not well
defined).
124
What to do with patient on hemodialysis/peritoneal dialysis after taking IV iodinated contrast media?
Okay to give IV contrast due to lack of toxicity.
1. hemodialysis: give IV contrast and no need to dialyze them afterwards.
2. peritoneal dialysis: caution should be taken if patient makes urine as IV contrast can reduce their urine output.
For both: caution on giving high volume of IV contrast due to fluid retention status of CKD.
125
which patient population to check their GFR (within 30 days) prior to IV iodinated contrast administration?
- history of renal disease (including dialysis, renal transplant, solitary kidney, renal cancer, or renal surgery),
- hypertension and diabetes mellitus.
126
How to reduce risk of CIN in CKD/AKI patients?
IV isotonic fluids: such as 0.9% saline or Lactated Ringer’s solution:
- 100 mL/h for 6 to 12 hours before contrast administration
- continued for 4 to 12 hours after exam.
127
to reduce risk of CIN in CKD/AKI patients, Administration of N-acetylcysteine has been widely studied and is now thought to be:
of no value
128
what medication is effective in reducing the risk of PC-AKI after cardiac catheterization.
high-dose statins
129
to reduce risk of "lactic acidosis --> CIN" after IV iodinated contrast administration to diabetic patients, in which two conditions metformin must be held?
1- GFR>30, do not hold metformin.
2- eGFR < 30, hold metformin (but in which case the patient should not be taking metformin anyway due to low GFR)
3- pt undergoing arterial catheterization with the risk of emboli to the renal arteries.
130
if metformin will be held prior to IV iodinated contrast administration, how long should it be held for?
withheld for 48 hours after contrast media administration and only reinstituted if the renal function is reassessed and found to be acceptable.
131
IV iodinated contrast, and pregnancy, breastfeeding, and babies?
- Iodinated contrast is safe for pregnancy and breastfeeding.
132
most severe complication of IV contrast extravasation?
1- compartment syndromes, which result from mechanical compression.
2- Skin ulceration and tissue necrosis.
133
when to consider surgical consultation after IV contrast extravasation?
1-Progressive pain (earliest and most reliable sign), swelling, decreased mobility, or sensation.
2-Altered tissue perfusion (decreased capillary refill),
3-Skin ulceration or blistering
134
Gadolinium-based contrast media (GBCM) are classified as
linear or macrocyclic, and ionic or nonionic.
135
Gadolinium-based contrast media (GBCM): nonionic agents are less or more stable than the ionic agents. Also what about linear or macrocyclic?
- Macrocyclic and ionic are more stable (opposite to iondiated contrast in which non-ionic is better).
- ionic agents are MORE stable than the nonionic agents.
- Marcrocyclic is more stable than linear: in macrocyclic, gadolinium ion is surrounded by a chelate ring --> more stable binding of the gadolinium ion within the chelate than do linear agents.
136
How many gadolinium-containing contrast agents are currently available for use in the United States?
Seven agents are approved in the USA:
1- Ionic agents (have -ate): Gadopentetate, Gadobenate, Gadoxetate, Gadoterate
2- non-ionic agents (does not have -ate): Gadodiamide, Gadoteridol, Gadobutrol
3- Linear (has di- in it): Gadopentetate dimeglumine, Gadobenate dimeglumine, Gadoxetate disodium, Gadodiamide
4- Macrocyclic (has -ter- in it): Gadoteridol, Gadobutrol, Gadoterate
137
which Gad agents are highest, lowerst, and no evidence of NSF?
If patient has Gad allergy, which one to avoid?
Group 1: highest risk.
Group 2: lowest risk.
Group 3: limited evidence for NSF.
If patient has Gad allergy, avoid: gadobenate dimeglumine [MultiHance ®]
138
A unique physiologic side effect of gadoxetate disodium (Eovist®) is
transient tachypnea, which can cause motion artifact on arterial-phase MRI.
139
Gad agent and pregnancy/breastfeeding?
- Safe during breastfeeding.
- Gad is class C: Do not use with pregnant women (secreted in the amniotic fluid), unless deemed urgent.
140
What body parts are affected by NSF ?
- Thickening and hardening of the skin, extremities, followed by trunk, but almost never on the face or head.
- Also: lungs, esophagus, heart, and skeletal muscles
141
NSF happen in which patient population, and when?
- CKD stage 4: GFR =15-29.
- CKD stage 5: GFR < 15.
- Happen after days-years from administration.
142
mechanism of NSF?
transmetallation: another metal replaces Gd from its chelate --> free toxic Gd ion
143
The three high-risk GBCM (Group 1: Omniscan, OptiMark, and Magnevist) are absolutely contraindicated by the FDA when the eGFR is less than?
less than 30 mL/min/1.73 m2.
144
immediate post-MRI dialysis reduces the risk of NSF in any high-risk GBCM- exposed patients?
Wrong. no data to prove that.
145
In which organs Gd retention happen?
globus pallidus and dentate nucleus (greater with linear than with macrocyclic agents).
146
Treatment of Hives (Urticaria)?
- None.
- Severe symptoms: diphenhydramine 50mg PO, IV, or IM. or fexofenadine (Allegra®), 180 mg PO.
147
Treatment of Diffuse Erythema, laryngeal edema, or Hypotension with Bradycardia or Tachycardia, and Unresponsive and Pulseless?
- In all patients: Preserve IV access, Give O2, 6 to 10 L/min (via MASK).
- Bronchospasm: beta-agonist inhaler albuterol, 2 puffs (90 mcg per puff); can repeat up to three times.
- Hypotensive: Elevate legs at least 60 degrees (Trendelenburg position). AND IV fluids (1L of 0.9% NS or LR).
- Hypotension with Bradycardia (pulse < 60 bpm) (Vagal Reaction): atropine, 0.6 to 1.0 mg IV to a total of 3mg.
- Hypotension with Tachycardia (pulse > 100 bpm):
1- epinephrine IV (1:10,000), 1 mL (0.1 mg) and repeat every 5-10 min for a total of 10mL slowly into a running infusion of IV fluids.
2- No IV access: epinephrine IM 1:1000, 0.3 mL (0.3 mg) and repeat to a total of 1mg.
3- if Pulseless/Unresponsive: epinephrine IV (1:10,000), 10 mL (1 mg), between 2-minute cycles of CPR, and repeat every 3-5min until return of circulation.
148
Reaction Rebound Prevention?
- corticosteroids are not useful in acute phase.
- To prevent short-term recurrence of an allergic-like reaction, Give hydrocortisone, 5 mg/kg IV over 1 to 2 minutes, or methylprednisolone, 1 mg/kg IV over 1 to 2 minutes.
149
Epinephrine pediatric (less than 30kg) dosing?
P.S: (bigger than 30Kg, treat them with adult dose).
- IM: autoinjector (EpiPen Jr®) (0.15 mg).
- IV: (0.01 mg/kg) of 1:10,000 dilution (maximum single dose of 1 mL [0.1 mg]), repeated every 5 – 15 minutes, as needed up to a maximum dose of 1 mg (10mL).
150
each physician service needs to be identifiable with a unique code that acts as the basis for payment, known as
Current Procedural Terminology (CPT)
151
which organization oversee the CPT coding?
American Medical Association (AMA)
152
After they are approved, CPT codes are evaluated
using Resource Based Relative Value Scale (RBRVS) methodology by the
AMA’s RBRVS Update Committee (RUC)
153
RUC then makes recommendations to CMS on the
Relative Value Unit (RVU) assignments.
154
The physician service’s total RVUs reflect
1) work RVU: encounter time, intensity, effort, and skill
2) practice expense RVU: costs of maintaining a practice, such as equipment, supplies, and non-physician staff
3) malpractice RVU: professional liability expenses.
155
The work RVU is used by many practices to
track physician productivity.
156
independently, Centers for Medicare and Medicaid Services (CMS) formally assigns RVUs to services and usually accepts
AMA RUC recommendations in more than 90% of cases.
157
RVUs are multiplied by ___ to determine CMS payments under the Medicare Physician Fee Schedule.
an annual Conversion Factor
158
CMS and private insurers generally pay only for services deemed medically necessary by
matching a CPT service code to a pre-approved diagnosis (ICD) code.
159
International Classification of Diseases (ICD) system, established by the World Health Organization, currently in its 10th revision (ICD-10). ICD-10 codes describe
the signs, symptoms, or specific diagnosis of a patient that form the indication for a healthcare service.
160
Terms such as “rule out” or “consistent with” are not capable
of being coded by ICD-10, and therefore:
do not meet medical necessity criteria.
161
Imaging corders are liscensed via
the Radiology Coding Certification Board
162
Coders extract ICD-10 information from radiology reports using any statements within:
1) examination indication and clinical history provided by the referring physician or patient
2) from any specific diagnostic information located in the findings section or (preferably) in the impression section of the radiologist’s report
163
Major payers contract with radiology benefit management (RBM) companies, and require
preauthorization (also known as precertification) - as a condition for reimbursement for any elective outpatient advanced imaging service.
164
As a general rule, preauthorization requirements do not apply to
emergency department and inpatient services.
165
A false claim ruling can result in fines of up to three times the billed amount plus $11,000 per claim filed, because each single exam or service billed to Medicare or Medicaid counts as a claim.
To date, the largest radiology practice government settlement agreement for allegations of fraud is $7 million.
166
HIPAA, stands for?
Health Insurance Portability and Accountability Act of 1996
167
(PHI),
protected health information
168
U.S. Department of Health and Human Services, the Office for Civil Rights (OCR) has responsibility for
enforcing these rules with civil money penalties.
169
how many zipcode digits is not a HIPAA violation?
first three digits of a ZIP code
170
The subsequent Declaration of Helsinki, now widely regarded as the cornerstone of human research ethics, has recommended that
all research protocols be reviewed by an independent committee prior to initiation.
171
Food and Drug Administration (FDA) regulations, an Institutional Review Board (IRB) has the authority to
approve, require modifications in order to secure approval, or deny approval for proposed research protocols.
172
The research informed consent process involves
1) providing adequate information about a study
to potential subjects,
2) providing an adequate opportunity for subjects to consider all options,
3) responding adequately to all subject questions,
4) ensuring that the subject comprehends all necessary information,
5) obtaining the subject’s voluntary agreement to participate, and
6) providing ongoing information as the subject or situation so requires.
173
The main cause of over-utilization in medicine?
Malpractice concerns have also been identified as a cause of overutilization of services; more than 90% of physicians report that they at least sometimes engage in the practice of defensive medicine.
174
what are the most common types of policies to protect physicians from personal financial liability?
“Claims-made” policies are the most common types of policies to protect physicians from personal financial liability, up to a predetermined policy cap, but only while the policy is in effect.
175
what's tail insurace?
physicians with claims- made policies thus usually need to arrange for tail insurance when changing jobs or retiring to ensure continued financial protection. “Occurrence” policies cover any claim for an event that took place during the period of coverage, even if a claim is filed after the policy lapses.
176
4 elements of malpractice?
1- established duty to a patient.
2- breach of duty, which usually involves a failure to meet the standard of care.
3- Causation must exist, in that the breach must have been the proximate cause of injuries. A radiologist, for example, may have negligently missed a lung mass on a chest radiograph
4- The negligence must result in damages. In many jurisdictions, emotional distress, pain, and suffering are frequently considered remunerative damages.
177
3 types of radiology malpractice errors
1) diagnostic errors,
2) procedural complications, and
3) communication deficiencies.
178
types of diagnostic errors in radiology:
1) failures of perception (i.e., not identifying a finding),
2) failures of interpretation (i.e., identifying a finding but not appropriately appreciating or adequately communicating its significance), or
3) combinations of both.
Also, Diagnostic/procedural/communication errors:
1) cognitive errors (e.g., not identifying a lung nodule when interpreting a chest radiograph), which are usually errors of visual perception (scanning, recognition, and interpretation), or
2) system errors (e.g., failure to adequately communicate the presence of that nodule)
3) procedural related errors: failure to minimize risk of errors/complication, and failure to treat it.
4) communicate results to clinician or at least patients
179
For findings that warrant immediate or urgent intervention, The Joint Commission (TJC) requires that professionals “report critical results of tests and diagnostic procedures on a timely basis.”
tension pneumothorax, ruptured aortic aneurysm, acute intracerebral hemorrhage, and pneumoperitoneum.
180
How long before reporting level one results?
Within 60 minutes of the time that the observation is made, and it must be documented.
181
What's level 2 results? and when to report?
Findings that may not require immediate attention but nonetheless may seriously impact a patient’s health, worsen over time, or result in an adverse outcome.
Example: intra-abdominal abscess or impending pathological hip fracture
Generally warrant communication within 12 hours.
182
"Level 3 results”, not time sensitive
Still important to document: Examples include a newly identified lung nodule or solid renal mass.
183
Communication should contain:
date and time of the communication, the person reporting the information, the person receiving the information, and a summary
184
“curbside consult”
To give undocumented professional opinion on an outside hospital exam. Not recommended.
185
Discoverability of Communications
physicians involved in lawsuits are strongly discouraged from speaking with any parties other than their attorneys about any elements of their cases.
186
Peer review is or is not protected against malpractice?
Protected.
187
DICOM
Digital Imaging and Communications in Medicine (DICOM) standard
188
DICOM uses?
specifies protocols for display, transfer, storage, and processing of medical images, including both storage of both pixel-based image data and metadata.
189
what's metadata?
The metadata, located in the “DICOM header” of the image, contains information about the image, series, exam, patient, imaging facility, and scanner.
190
How can DICOM prevents medical errors?
By transmitting exam information between the radiology information system ("RIS") and the "modality" (e.g., the CT, MR, or ultrasound machine) rather than having to be manually entered by the technologist and risking incorrect data entry.
191
What is The radiology information system (RIS)?
RIS is a software application that manages all aspects of an imaging exam, including order reconciliation, patient scheduling and tracking.
RIS is the middle guy for communication between: modalities and PACS, reporting, results notification, and billing.
The RIS may be a standalone application or a component of the electronic medical record (EMR) application.
Both PACS and RIS can be used to drive clinical workflow.
192
what's HL7 (http://www.hl7.org)?
HL7: exchange of medical information among various systems to achieve systems "interoperability" (i.e., exchange of text data among various softwares, not image data which are handled by DICOM).
The HL7 V2 messaging standard is generally
considered to be the most widely implemented
healthcare-related standard in the world.
HL7 V3, while more human-readable, has been LESS widely adopted in the industry because of its increased complexity.
193
Ontologies?
Ontologies are formal collections of terms, their definition, and their relationships.
194
RadLex?
the largest radiology-specific lexicon. It contains more than 68,000 terms that describe imaging anatomy, procedures, and pathology.
195
RadLex Playbook?
Defines standard imaging exam names, descriptions, and codes, currently merged with LOINC.
196
LOINC (Logical Observation Identifiers Names and Codes)?
the international standard nomenclature for health measurements, observations, and documents.
197
PACS?
The PACS (picture archiving and communications system) is the radiologist’s primary tool for imaging viewing and interpretation.
Modern PACS can be entirely web-based and accessible on mobile devices as well as on desktop thin clients.
Basic components of PACS include a workstation, display, short-term storage, and long-term archive.
198
How communication happens from patient arrives to ED to receiving their CT/MR/XRAY report?
1- Pt arrives to ED, seen by MD, then MD puts an order in the EMR.
2- EMR send a message to RIS via HL7.
3- RIS communicates with modality via the DICOM Modality Work List.
4- Modality sends images to PACS via DICOM transaction.
5- Radiologist reads the images at PACS station, sign and report, and report is send to RIS/EMR via HL7.
6- Doctor and pt now can be view report in EMR/pt portal.
199
PACS communication?
PACS communicates with imaging modalities using DICOM transactions,
PACS communicates with the RIS/EMR using HL7 transactions that are translated to and from DICOM.
200
VNA?
The vendor-neutral archive (VNA) allows data to be stored in a central archive that may support viewers for multiple types of DICOM images (e.g., radiology, cardiology, operating room, etc.), as for non-DICOM data, including photographs and pathology slides.
201
Illuminance vs Luminance?
• Illuminance = ambient light intensity of the reading room:
- 25 to 50 lumens/m^2 (lux).
• Luminance = monitor brightness in candela/m^2.
- 350 cd/m^2 for general radiology.
- 420 cd/m^2 for mammo.
202
Lossless vs Lossy compression of files?
- lossless: 3:1 compression, with removal of redundant stuff (black background of
a CT image).
- Lossy: 10:1 irreversible compression, causing loss of minimally important image information without significantly compromising diagnostic quality.
203
Ergonomics?
Workstation configurations that promote a neutral body position with the forearm, wrist, and hand parallel to the floor, lumbar support, and appropriate distance between the user and the display can help to decrease the incidence of repetitive strain injuries (RSI) among radiologists.
204
What are the component of downtime?
Downtime procedures include disaster recovery (DR) and business continuity (BC) procedures.
205
disaster recovery (DR)?
It is the attempt of engineers to restore the main software back online so that radiologists can continue reading.
206
business continuity (BC)?
It is the backup software (simple low key software) that you can run on any computer when the main PACS crashes, so that workflow continues without interruption.
207
high-availability (HA) systems.
Radiology is a HA systems, by # of nines.
- four 9's means: 99.99% of uptime, which equals to 50 minutes downtime per year.
- five 9's means: 99.999%, which equals to 5 minutes downtime per year.
208
Fault tolerance (FT)?
It is when software is built with redundancy (more line code per each branching point) so that if one failed, the next continues to achieve high FT.
209
protected health information (PHI), as defined by HIPAA, and can be de-identifiable using specialized algorithm or “burned-in” PHI, such as?
Ultrasound image where pt info is burned into the image header. This is vs CT/XRAY where HPI is in the metadata header of the DICOM image.
Other pt HPI is head CT/MRI as it has pt face.
210
Post-processing includes techniques such as image segmentation, registration, and iterative reconstruction. What's segmentation?
- Segmentation involves isolating or extracting a region of interest (e.g. software extracting gray matter and calculate volume to assess brain atrophy).
211
Image registration
involves aligning one image set onto the coordinate space of another image set to allow a more direct comparison of the two image sets.
Deformations can be rigid (translation, scaling), affine (shearing), or elastic.
Elastic deformation involves local warping of an image to better align the target image with the reference image.
Elastic deformation is one type of image registration that can accommodate changes such as patient position, lung expansion, or soft tissue shape changes in aligning image sets.
212
Iterative reconstruction
is an alternative to filtered back-projection as a method for reconstructing raw CT sinogram data into actual image data.
Iterative reconstruction performs several rounds of image reconstruction to optimize the signal and reduce the noise in the resulting images.
Noise reduction enables the use of less radiation to acquire the images prospectively, decreasing patient radiation exposure.
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Artificial intelligence (AI)
is the field of computer science that gives computers the ability to mimic human intelligence.
214
Machine learning (ML)
is a subfield of AI that enables computers to learn a task without being given an explicit set of instructions.
215
Supervised ML
Supervised ML exposes an algorithm to a set of training data, and then evaluates how well the resulting model has “learned” the task using a different set of testing data. Generating training data for radiology requires experts to label images or text, which is time- and resourceintensive.
216
“black box”
Major challenges in deploying AI for radiology include understanding how the “black box” model produces its results, ensuring that the model performs reliably in all potential applied settings and conditions, and efficiently integrating the model into the clinical workflow.
NIS 2021
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