Non interpretive skills Flashcards
(208 cards)
1
Q
What is the definition of professionalism?
A
“A calling requiring specialized knowledge and often long and intensive academic preparation.”
OR “the conduct, aims, or qualities that characterize or mark a profession or professional person”
2
Q
What are the three fundamental principles of professionalism?
A
- Principle of primacy of patient welfare
- Principle of patient autonomy
- Principle of social justice Created by the American Board of Internal Medicine
3
Q
Describe the principle of patient welfare
A
Physicians must be dedicated to serving the interest of the patient. Trust is central to the physician-patient relationship, which must not be compromised by market forces, societal pressures or administrative exigencies. **fundamental principle of medical professionalism**
4
Q
Describe the principle of patient autonomy
A
Physicians must be honest with their patients and empower them to make informed decisions about their treatment.
Patients’ decisions about their care must be paramount, as long as they are in keeping with ethical practice and do not lead to demands for inappropriate care.
**fundamental principle of medical professionalism**
5
Q
What are the 10 professional responsibilities?
A
- Commitment to professional competence
- Commitment to honesty with patients
- Commitment to patient confidentiality
- Commitment to maintaining appropriate relations with patients
- Commitment to improving quality of care
- Commitment to improving access to care
- Commitment to a just distribution of finite resources
- Commitment to scientific knowledge
- Commitment to maintaining trust by managing conflicts of interest
- Commitment to professional responsibilities
6
Q
Describe the principle of social justice
A
The medical profession must promote the fair distribution of healthcare resources.
Physicians should work actively to eliminate discrimination in healthcare.
**fundamental principle of medical professionalism**
7
Q
What are the 13 ethical considerations specific to radiology? They are described the in ABR Bylaws
A
- Professional limitations
- Reporting of illegal or unethical conduct
- Report signature. Radiologists should not sign a report or claim attribution of an imaging study interpretation that was rendered by another physician, making the reader of the report believe that the signing radiologist was the interpreter.
- Participation in quality and safety activities.
- Self-Referral
- Harassment
- Undue influence - radiologists should seek to ensure that the system of healthcare delivery in which they practice does not unduly influence the selection and performance of appropriate available imaging studies or therapeutic procedures
- Agreements for provision of high-quality care.
- Misleading billing arrangements.
- Expert medical testimony. Radiologists should exercise extreme caution to ensure that the testimony provided is nonpartisan, scientifically correct and clinically accurate. Compensation that is contingent upon the outcome of the litigation is unacceptable.
- Research integrity
- Plagarism
- Misleading publicizing
8
Q
Quality definition
A
” a high level of value or excellence” or “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes are consistent with current professional knowledge.”
9
Q
What are the two important dimensions of quality?
A
Excellence and consistency (performance must be monitored to ensure consistency)
10
Q
What are the two main goals of quality?
A
1) maximize the likelihood of health outcomes desired by the patient and
2) satisfy the patient patient= arbitrator of quality In order to ensure that outcomes are consistent with current professional knowledge…
- another goal is decreasing unnecessary variation in process and outcomes. Usually requires collaboration and adherence to practice standards based on evidence
11
Q
Quality control (QC) definition?
A
Measuring and testing elements of performance to ensure that standards are met and correcting instances of poor quality.
Ex. Radiologist reviews and corrects errors in a report before finalizing it. **most basic level of quality-related activities in an organization**
12
Q
Quality assurance (QA) definition?
A
Refers to a process for monitoring and ensuring performance quality in an organization. This includes QC activities, but also refers to strategies designed to prevent instances of poor quality. Ex. Standardized report template to minimize errors in reporting accompanied by verification of appropriate use with audit-based performance metrics **Designed to MAINTAIN rather than improve performance- assumes performance was adequate in the first place **more comprehensive than QC and is required to maintain consistent high performance in an organization*
13
Q
Quality improvement (QI) definition?
A
Activities designed to improve performance quality in an organization in a systematic and sustainable way.
This requires a deliberate effort within an organization to agree on a measurable performance objective, measure the relevant performance, understand the causes of poor performance, develop and implement strategies to improve performance, and ensure that those strategies are embedded in the organization such that performance will not relapse.
Ex. Project whereby radiologists agree to improve consistency in reporting using standardized radiology report templates, implement those templates, monitor radiology reports and make necessary adjustments and ensure that consistency is maintained through feedback and accountability **Assumes that quality isn’t as good as it good be and employs strategies to improve it **Field has evolved now to a focus on continuous quality improvement (CQI)
14
Q
Four ways that quality methods have evolved?
A
- Quality is recognized as everyone’s responsibility - especially organizational leaders
- Focus shifted from detecting and correcting errors that have already occurred to creating systems to prevent errors from happening or causing harm
- Front-line staff are engaged to help improve processes
- The value of making errors visible rather than quietly fixing them without sharing them is increasingly recognized.
15
Q
“Crossing the Quality Chasm” Asserts that healthcare should be what 6 things?
A
Purpose is to reduce the burden of illness, injury and disability and improve the health and function of the people of the US by making healthcare:
- Safe
- Effective
- Patient-centered
- Timely
- Efficient
- Equitable
16
Q
ABMS and the ACGME created what six core competencies that all physicians should attain?
A
- Practice-based learning and improvement
- Patient Care and procedural skills
- Systems-based practice
- Medical knowledge
- Interpersonal and communication skills
- Professionalism
17
Q
Define Practice-based learning and improvement?
A
Show an ability to investigate and evaluate patient care practices, appraise and assimilate scientific knowledge, and improve the practice of medicine.
18
Q
Define Patient Care and Procedural Skills?
A
Provide care that is compassionate, appropriate and effective treatment for health problems and promote health.
19
Q
Define Systems-based practice?
A
Demonstrate awareness of and responsibility to the larger context and systems of healthcare. Be able to call on system resources to provide optimal care (e.g. coordinating care across sites or serving as the primary care manager when care involves multiple specialties, professions or sites).
20
Q
“To Err is human: Building a safer Health System” was developed by whom?
A
2000 Institute of Medicine Report- the first seres of reports arising from the project below In 1998, the National Academy of Sciences’ Institute of Medicine (IOM) initiated the Quality of Health Care in America project to develop a strategy that would result in an improved quality of care in the US.
21
Q
What were the main findings reported in To Err is Human?
A
44,000 - 98,000 in-hospital deaths per year were attributable to medical errors – exceeding MVAs, breast cancer or AIDs – Costing soceity between 17 and 29 billion dollars
22
Q
What is a medical error?
A
the failure to…
1) establish an accurate and timely explanation for a patient’s health problem
2) communicate that explanation to the patient with the highest risk for errors occurring in high-acuity environments
1/6 likely have had an experience with diagnostic error and 10% of postmortem exams were associated with diagnostic errors - the diagnostic process should also be collaborative including multiple professionals and professional groups
23
Q
What are the 4 fundamental factors contributing to medical errors?
A
1) The decentralized nature of the healthcare delivery system (or nonsystem)
2) the failure of licensing systems to focus on errors
3) the impediment of the liability system to identify errors
4) the failure of third-party providers to provide financial incentive to improve safety *most are multi-factorial- including unsafe systems and processes of care as well as human error”
24
Q
What 8 specific recommendations were made to the 2015 Institute of Medicine Report, Improving Diagnosis in Health Care?
A
- Facilitate more effective teamwork among health professionals, patients and their families. Radiologists and pathologists are an integral part of the diagnostic team.
- Enhance healthcare professional education and training in the diagnostic process.
- Ensure that health information technologies support patients and healthcare professionals.
- Develop and deploy organizational approaches to identify, learn from and reduce diagnostic errors and near misses in clinical practice.
- Establish a work system and culture that supports the diagnostic process and improvements in performance. This may include redesigning payment structures since fee for service (FFS) payments lack incentives to coordinate care among team members, such as communication among treating clinicians, pathologists and radiologist about diagnostic test ordering, interpretation and subsequent decision making
- Develop a reporting environment and medical liability system that facilitates improvement
- Design a payment and care delivery environment that supports the diagnostic process. Specifically, oversight bodies should require that healthcare organizations have programs in place to monitor the diagnostic process and identify, learn from, and reduce diagnostic errors and near misses in a timely fashion.
- Provide dedicated funding for research on diagnostic process and diagnostic errors.
**also stated that failures in communication were the significant contributor to diagnostic error**
25
How should IT professionals and organization leaders improve communication?
1. Standardize communication policies and definitions across networked organization
2. Ensure clear identification of the patient's care team to facilitate contact by the radiology team
3. Implement effective results management and tracking processes
4. Develop shared quality and reporting metrics
26
What does Human Factors Engineering do?
Focuses on how systems work in actual practice with real and fallible human beings at controls- design systems that optimize safety and minimize risk of error in these environments
Takes into account human strengths and limitations in the design of interactive systems that involve people, equipment, technology and work environments to ensure safety, effectiveness, and ease of use.
Examines a particular activity in terms of its component tasks and then assesses the human physics, mental and skill demands in the context of team dynamics, work environment and device design required to optimally perform a task \*\*\*They recommend STANDARDIZATION-- including the use of checklists\*\*
27
What are the two parts of communication?
1. Conveyance-- transmission of information from a sender to a reciever
2. Convergence-- verification, discussion and clarification until both parties recognize that they mutually agree (or fail to agree) on the meaning of the information
28
What is a High Reliability Organization?
An organization that despite operating in a high-stress, high-risk, complex environment, continually manages its environment mindfully, adopting a constant state of vigilance that results int he fewest number of errors. They maintain resilience through stressful situations by both anticipating unexpected events and containing their impact when they do occur.
29
What are the three components to anticipation of HRO?
1. Preoccupation with failure - recognize that even minor lapses in judgement can have severe consequences - watch deliberately for clues that indicate trouble - have processes in place to enable individuals, teams, and systems to quickly detect and respond to a potential threat before harm
2. Reluctance to simplify - do not accept a simple explanation to a problem, dig deeper to the source of the problem
3. Sensitivity to operations -leaders understand the messy reality of the details of what is actually happening in the place of work rather than what is supposed to be happening and respond accordingly
30
What are the 2 elements of containment in regard to HRO?
1. Commitment to resilience
2. Deference to expertise - no one individual ever knows everything about a situation - people with greatest authority often have less useful knowledge about a situation than those with lesser authority
31
What is the "skill-rule-knowledge" SRK model?
Refers to the cognitive mode in which the individual is operating when he or she commits an error. Actions that are usually performed automatically, requiring little conscious attention, are considered skill-based actions (i.e. tying one's shoes) Actions that require an intermediate level of attention are considered rules-based actions (i.e. deciding which clothes to wear or when to proceed at a four-way stop) Actions that require a high level of concentration, usually in the setting of situations that are new to an individual, are knowledge-based actions, (i.e. playing a sport for the first time or driving in poor visibility in a new city)
32
How do you fix a skill-based error?
Behavior-shaping constraints that make it hard to perform the wrong action( (i.e. forced functions) and enablers that make it easy to perform the right action)
33
How do you fix a rules-based or knowledge-based error?
Increased supervision, additional training and coaching, deliberate practice and intelligent decision support.
34
Features of a culture of safety?
1. Acknowledgement of the high-risk nature of an organization's activities and the determination to achieve consistently safe operations. 2. A blame-free environment where individuals are able to report errors or near misses without fear of reprimand or punishment. 3. Encouragement of collaboration across ranks and disciplines to seek solutions to patient's problems 4. Organizational commitment of resources to address safety concerns
35
Underlying reasons for an underdeveloped healthcare safety culture (4)?
1. Poor teamwork 2. Poor communication 3. Culture of low expectations 4. Presence of steep authority gradients
36
What are the differences in just culture?
1. Human error (slip) - product of our current system design and behavioral choices (Console patient) - modify available choices, changes processes/workflows, improve training programs, redesign system or facility 2. At-risk behavior (shortcut) - Choice where the risk is believed to be insignificant or justified (coach) - counsel individual, better incentivize correct behavior, modify processes, training as needed 3. Reckless behavior (flaunting firmly established safety rules) - Conscious disregard for substantial and unjustified risk (punish/sanction) - remediate or remove from the environment, take punitive action
37
What are the two types of quality improvement activities?
1. Frequent small improvement efforts conducted in close association with the management of the day-to-day clinical operations 2. Dedicated improvement projects to address areas of performance that generally require more focused improvement efforts
38
What are the core elements to help a Daily Management System improve day to day operations?
1. Tiered Huddles 2. Goal and Metrics Review 3. Daily Readiness Assessment 4. Problem Management and Accountability Cycle 5. Regular Follow-up 6. Frequent Visits to the Workplace
39
Goals of a Daily Management System?
To facilitate communication and coordination across organizational units or roles in the organization (i.e. in radiology would be between 1. radiologists, technologists, medical assistants, IT professionals and administrators; 2. front line staff, managers, and leaders; 3. the radiology department and other units such as the ER, inpatient units and medical and surgical specialties)
40
What is Zone 1 in MR safety?
Access if unrestricted. Includes all areas that are freely accessible to the public. This is the area through which patients and others access the MR environment.
41
What is Zone II in MR safety?
Interface between the uncontrolled zone 1 and the strictly controlled zone III and IV. May greet patients, obtain histories, screen patients for MR safety issues. Patients in this zone should be under supervision of MR personnel
42
What is Zone III in MR safety?
Area where there is potential danger from serious injury or death from interaction between unscreened people or ferromagnetic objects and the magnetic field of the scanner. Ex. Scanner control room. Access to zone III must be strictly restricted and other the supervision of MR personnel, with physical restriction such as with locks and passkey systems.
43
What is Zone IV in MR safety?
Magnet Room and is highest risk. Zone should be clearly demarcated as potentially hazardous because of the strong magnetic field. Access to Zone IV should be under the observation of MR personnel. When a medical emergency occurs, 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.
44
What should happen for people working within zone III?
Should pass an MR safety screening process and have specific education on MR safety.
45
What should be done about ferromagnetic objects?
They should be restricted from entering Zone III whenever practical. All MR sites should have a handheld magnet (\> or equal to 1000 Gauss) or handheld ferromagnetic device, which allows for testing of all external objects and some superficial internal implants... if the do enter MR zone III, they must be secured at all times and under the direction o the MR personnel
46
What should be done during screening?
If patient is unconscious or unable to provide a history, history should be from family members, medical record and the need for the exam should be balanced. MR personnel should look for surgical scars.
47
What is the line past which electromagnetic devices are not safe?
5 Gauss line - should be marked on floors for safety
48
Are aneurysm clips safe?
Some are and some aren't like pacemakers. There has been one fatality from an aneurysm clip in the scanner. MRI should not be performed until the manufacturer, model and type of aneurysm clip has been deemed MR safe or MR conditional. If a prior MRI had been done, that does not mean it is safe.
49
What should be done if MRI is performed on a patient with a pacemaker or ICD?
Ensure it is MR conditional or safe. Radiology and cardiology should be present as well as a crash cart (especially for conditional devices)
50
MRI and pregnancy?
Safe as long as you don't give gadolinium.
51
Pregnant healthcare workers and MRI?
Safe to work in the MRI environment for all stages of pregnancy, but they should not remain in Zone IV during data acquisition or scanning.
52
Possibility of thermal injury and burns in MRI?
Risk is from radio-frequency fields Physical contact alone with the inner surface of the bore can produce burns!
Insulating pads are needed to keep skin at least 1-2 cm from the surface. \*\*PAD!\*\*
In a large patient, tightly wedging a sheet in place of a pad between the skin and the bore, not maintaining the requisite distance, creates a distinct risk of burns. RF fields can also induce currents within the body when there is a "closed loop" formed (i.e. skin to skin contact at the inner thighs). If there is only a small area of sin-to-skin contact, greater current density and restive heating can lead to burns. Skin-to-skin burns have also occurred when overhanging abdominal panniculus in an obese patient contacts the upper thigh. Other causes, metallic fibers in closing (especially undergarments).
Most patients change into hospital gowns for the MRI. Loops of metallic wire, patches of wire, other electrical conduction circuits may rapidly heated by RF pulses during normal operation of an MR system. Also, transdermal patches may contain aluminum or other metals and can cause burns. Rarely large tattoos may cause burns (can place an ice pack to reduce the risk of burning)
53
Possibility of thermal injury and burns in MRI?
Risk is from radio-frequency fields Physical contact alone with the inner surface of the bore can produce burns! Insulating pads are needed to keep skin at least 1-2 cm from the surface. \*\*PAD!\*\* In a large patient, tightly wedging a sheet in place of a pad between the skin and the bore, not maintaining the requisite distance, creates a distinct risk of burns. RF fields can also induce currents within the body when there is a "closed loop" formed (i.e. skin to skin contact at the inner thighs). If there is only a small area of sin-to-skin contact, greater current density and restive heating can lead to burns. Skin-to-skin burns have also occurred when overhanging abdominal panniculus in an obese patient contacts the upper thigh. Other causes, metallic fibers in closing (especially undergarments). Most patients change into hospital gowns for the MRI. Loops of metallic wire, patches of wire, other electrical conduction circuits may rapidly heated by RF pulses during normal operation of an MR system. Also, trans-dermal patches may contain aluminum or other metals and can cause burns. Rarely large tattoos may cause burns (can place an ice pack to reduce the risk of burning)
54
What is a Quench?
Occurs when heating of a segment of the electromagnetic coils makes them no longer superconducting.
This produces further heat within the coils and collectively, these events produce a rapid change of state of the liquid helium into a gas (with a 760 fold increase in volume).
A quench pipe accommodates the explosive force of the rapidly boiling helium gas by allowing it to escape into the atmosphere.
55
How is the MRI kept cool?
Bathing the electromagnetic coils of the MR scanner in large volumes (usually 1500-2000 L) of extremely cold liquid helium (-269 degrees C, 4-K degrees).
56
What if the quench pipe fails?
Enormous volume of cold helium gas will flow into the magnet room and would displace oxygen to the floor and increase the risk of asphyxiation. It would make a fog making it hard to see. An inward swinging door would great the risk of positive pressure entrapment. Evacuate Zone IV prior to a quench
57
What are all ionized contrast media derived from? How can they be classified?
Tri-iodinated benzene rings
Nonionic or ionic
Monomeric or dimeric
58
Describe the differences between ionic and nonionic contrast?
Ionic contrast dissociate into two particles in solution (an anion, which contains the tri-iodinated benzene ring and a cation, consisting of sodium or methylglucamine). Nonionic contrast media are hydrophilic molecules that do not need to be conjugated with cations to be water soluble. They do not dissociate in solution.
59
What is the difference between monomeric or dimeric contrast?
Monomeric contrast molecules contain only one tri-iodinated benzene ring, while dimeric contrast molecules contain two jointed tri-iodinated benzene rings.
60
What are high-osmolality contrast media?
Standard iodine concentrations, ionic monomeric contrast media have the highest osmolality (roughly 4x human serum) NOT USED for IV injection in the US because they are associated with higher rates of adverse reactions than the nonionic monomeric or dimeric contrast media
61
What is the osmolality of nonionic monomeric contrast media?
Nonionic monomeric contrast media have about half the osmolality of high-osmolality contrast media and roughly twice that of serum. (of note nonionic dimers have similar osmolality to plasma and are referred to iso-osmolality contrast media)
62
What type of contrast is used for intra-arterial injection??
Iso-osmolality media are sometimes used for intra-arterial inejction (rarely intravenous injection). Ex of iso-osmolality contrastm edia are nonionic dimers and have a similar osmolality to plasma
63
What nonionic, low-osmolality contrast media are approved for IV use in the US?
Iohexol (omnipaque)
iopamidol (Isovue)
Iopromide (Ultravist)
Isoversol (Optiray)
Ioxilan (Oxilan)
Only one iso-osmolality contrast= iodixandol (Visipaque)
64
What is the risk of adverse contrast reaction of any time in patients with non-ionic contrast media?
3%
65
Do contrast reactions require sensitization?
No. You do not need exposure to get the antigen-IgE antibody response. Therefore, they are call "Allergic-like"
66
Are physiologic reactions dose related? What causes them?
Yes. They are due to direct toxic effects of contrast
67
What are some mild physiologic reactions?
1. Nausea and Vomiting
2. Flushing and warmth
3. Chills
4. Headache
5. Anxiety
6. Altered taste
7. Mild HTN
8. Spontaneous resolving vasovagal reaction
68
What are some mild allergic-like reactions (6)?
1. Hives
2. Pruritus
3. Limited Cutaneous Edema
4. Itchy/scratchy throat
5. Nasal congestion
6. Repetitive sneezing, stuffy nose
69
What are some moderate physiologic reactions?
1. Protracted nausea
2. Chest pain
3. Vasovagal reaction that requires and is responsive to treatment
70
What is the difference between mild, moderate and severe reactions?
Mild- signs are self limited and without progression
Moderate - signs and symptoms are more pronounced and commonly required medical treatment
Severe- signs and symptoms are potentially life threatening and can result in permanent morbidity or death if not managed correctly
71
What are moderate allergic-like reactions?
1. Diffuse hives
2. Diffuse erythema (with stable vital signs)
3. Facial edema without dyspnea
4. Wheezing with mild or no hypoxia
72
What are severe physiologic reactions?
1. Vasovagal reaction resistant to treatment
2. Arrhythmia
3. Seizures
4. HTN crisis
5. Pulmonary edema
6. Cardiopulmonary arrest
73
What are severe allergic reactions?
1. Diffuse edema or facial edema with dyspnea
2. Erythema with hypotension
3. Laryngeal edema with stridor and/or hypoxia
4. Wheezing with hyoxia
5. Severe hypotension and tachycardia
6. Pulmonary edema
7. Cardiopulmonary arrest
74
How common are allergic-like reactions? How many are severely life threatening?
\<1 %
0.01-0.04%
75
What are risk factors for adverse reaction to contrast media?
1. Prior allergic reaction to same class of contrast have 5x the risk
2. Pt with other allergies and asthma are 2-3x as likely (Not shellfish or iodine allergy OR reaction to gadolinium increasing risk for iodine or vice versa)
76
What diseases are exacerbated by administration of contrast?
1. severe CKD and AKI
2. Cardiac arrhythmia
3. CHF
4. Myasthenia gravis and severe hyperthyroidism
77
How long should you wait after iodinated contrast before radioactive iodinated treatment?
4-6 week because contrast will saturate the thyroid gland and make treatment ineffective
78
Who gets pretreatment?
Patients with prior moderate or severe allergic-like reaction to the same class Remember to screen for contrast allergies!
79
What are the most widely acceptive premedication regimens?
1. a. oral 50 mg prednisone 13, 7, and 1 hour before contrast b. 50 mg of Benadryl 1 hr before injection
2. 32 mg of methylprednisolone 12 and 2 hour before treatment
80
What is the pediatric regimen?
0.5-0.7 mg/kg of oral prednisone 13, 7 and 1 hour before contrast and benadryl 1 hr prior to injection (dose of 1.25 mg/kg, up to max dose of 50)
81
What is a common rapid prep?
200 mg of hydrocortisone q4 hours until the study is performed (recommend 2 doses) + 50 mg of Benadryl 1 hour before contrast
82
Proven benefit of corticosteroid premedication? Greatest risk of premedication?
Reduction of mild reactions in an average-risk individual Delay in care - can delay diagnosis, increase cost, expose to hospital infections etc.
83
What are the symptoms of breakthrough reactions usually?
80% similar severity to initial reaction, 10% less severe, 10% more severe
84
Can someone who broke through be reinjected in the future?
Yes. Reaction will often not occur and if it does, it will be similar in severity.
85
Complications of pretreatment?
Transient hyperglycemia exacerbation of infection peptic ulcer disease steroid psychosis tumor lysis syndromes
86
PC-AKI definition and onset?
Postcontrast acute kidney injury = sudden deterioration in renal function after IV iodinated contrast onset is usually 24-48 hours after contrast \*correlative\*
87
CIN?
Contrast-induced nephropathy = sudden deterioration in renal function caused by IV iodinated contrast
88
Who gets CIN?
Less common than thought and in pt with severe CKD (GFR \<30) \>45 very unlikely 30-45 questionable
89
PC-AKI definition?
1) absolute serum Cr increase of at least 0.3 mg/dL
2) a percentage increase in serum creatinine of at least 50% (1.5 fold above baseline
3) reduction in urine output to 0.5 mL/kg/hr for 6 hours (also note there is dose-toxicity with patients getting lots of doses within 24-48 hours- mostly shown in coronary arteriography patients)
90
Clinical course of PC-AKI (including CIN)?
Initial rise in Cr beginning in 24 hours of contrast
Cr peaks at 4 days and returns to baseline at 7-10 days
Permanent dysfunction is unusual
91
Risks for AKI but not necessarily CIN?
DM, dehydration, CVD, diuretic use, advanced age, multiple myeloma, HTN, and hyeruricemia
92
Risk to hemodialysis patients with IV contrast?
theoretic risk of additional renal compromise. Trouble if the fluid status is brittle and may cause fluid overload (of the small volume hyperosmolar contrast). No need to time HD. May be more risky for patients on PD because of the dependence on urine output.
93
Indications for prophylatic screening of kidney function before scanning?
history of renal disease (HD, transplant, solitary kidney, renal cancer, renal surgery) HTN and DM
if patient is clincially stable and has a cr \<30 day= OK
94
Minimize risk of PC-AKI? Minimize CIN in at risk patients?
IV volume expansion with isotonic fluids (0.9% saline or LR) 100 mL/h for 6-12 hours after contrast administration (N-acetylcysteine is not helpful - as well as other agents) \*\*high dose statins are effective in reducing the risk of pC-AKI after cardiac cath\*\* Look for alternatives, if you have to give contrast- make it the smallest dose you can
95
Metformin is contraindicated in renal dysfunction because?
Very small percentage will develop lactic acidosis leading to 50% mortality rate
96
What if a patient receiving metformin develops AKI after contrast?
Increased risk of lactic acidosis But metformin itself is not a risk factor for the development of CIN
97
Precautions for diabetic patients on metformin?
No precautions as long as the GFR \>30 (and the patient shouldn't be on metformin anyway) or the patient is undergoing arterial catheterization with risk of emboli to the renal arteries -- in this case it should be withheld for 48 hours after contrast administration and only resumed if renal function is reaccessed and found to be acceptable
98
Are there any risk of Iodinated contrast media in pregnancy?
Can cross the placenta but no evidence that maternal exposure is harmful to the fetus.
99
How much of iodinated contrast will pass into the breast milk?
1% and then only 1% of this is absorbed by the infant's GI tract
this is \<1% of the recommended infant dose of iodinated contrast media for the infant
Inform the mother and tell her that studies are limited but little risk- mom can abstain for 12-24 hours and discard if she wants
100
What is the rate of extravasation?
0.1-1.2% risk
101
Risk for extravasation of contrast?
1. more likely with poor catheter insertion technique
2. peripheral access sites (hand, wrist or ankle)
3. indwelling lines that have been in place for more than 24 hours (phlebitis is likely present)
4. multiple punctures to the same vein
102
Risk factors for increased volume of extravasated contrast?
1. patient's inability to communicate (infants, young adults, young children, patients with altered consciousness)
2. severe illness
3. debilitation
103
Symptoms of Extravasation?
Swelling or tightness and/or stinging or burning pain at the site PE: edema, erythema or tenderness 98% resolve on their own 2% contrast damages tissues - pain and swelling Severe extravasation is \<1%
104
Symptoms of severe extravasation?
Compartment syndrome symptoms (mechanical compression)- more likely with a large volume in a small space
Less likely are skin ulceration and skin necrosis
(the above need a surgery consultation!)
lymphedema, reflex sympathetic dystrophy are extremely rare
Increase risk if arterial insufficiency or compromised venous or lymphatic drainage
May be immediate or after a period of time- monitor patients to ensure resolution or improvement Discharge with look out for: worsening pain, failure of existing pain to improve, decreasing arm, wrist or finger motion; loss of sensation or paresthesia in the affected extremity and skin breakdown
105
Symptoms that indicated prompt surgical evaluation?
1. Progressive swelling or pain
2. decreased finger mobility
3. altered tissue perfusion (change in capillary refill)
4. change in sensation
5. skin ulceration or blistering
\*\*earliest and most reliable sign of severe injury is severe or progressive pain\*\*
106
How are Gadolinium-based contrast media defined?
- They all usually include a moiety called a chelate
- Linear or macrocyclic
* Macrocyclic have the gadolinium surrounded by the chelate ring and are more stable than linear
* Among the linear, nonionic linear agents are less stable than ionic
- Ionic or Nonionic
107
How frequent are adverse reactions to GBCM than iodinated contrast?
2-4 times less frequent
Similar types of reactions
108
What are some typical side effects of GBCM?
_Usually mild and non-allergic (physiologic)_
* colness at injection site
* nausea without vomiting
* headache
* warmth or pain at injection site
* paraesthesias
* dizziness
_Most common allergic like symtoms_
* hives, rash, urticaria
* respiratory and cardiovascular reactions can occur
* death is rare
109
What is a unique side-effect of Eovist (Gadoxetate disodium)?
Tachypnea
Can cause motion artifacts on arterial-phase MRI- more common with high-volume and off-label administrations
110
Risk Factors to GBCM?
previous reaction to these agenets
Allergies or asthma (less risk)
Prior allergic-like reactions to iondinated contrast IS NOT a risk factor
111
Preventative measures for GBCM prior contrast reaction?
Try a different type of contrast
Note that MultiHance (gadobenate dimeglumaine) states that it is contraindicated in patients with prior allergic-like contrast reactions to ANY GBCM
Premedication (not been tested)
112
GBCM in Pregnancy safe? What class?
No. Class C drugs.
No studies have been performed in humans. In animals- it can pass the placental barrior, enter fetal circulation, filter by fetal kidneys and be exreted into the amniotic fluid and live there forever
113
GBCM in women breastfeeding?
Tiny amounts (0.04%) of administered GBCM are excreted into the milk and only 1% is absorbed by the infant. No evidence of adverse effects.
(Same as iodinated- inform mom and she can stop if she wants)
114
Symptoms of NSF?
Fibrosing disease most evident in the skin and subcutaneous tissues but can involve other organs too. Skin thickening with plaque formation. Symptoms may progress rapidly with some patients getting contractures and joint immobility -- could be fatal
No treatment
115
Who is at risk for NSF?
Patients with severe CKD (stage 5, eGFR =15-29 mL/min or stage 5, eGFC \<15) or patient with AKI who has been exposed to GBCM
Can occur days to years after GBCM
\*\*Immediate HD does not help\*\*
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What are the high risk GBCM for NS?
Linear GBCM
1. Omniscan (gadodiamide)
2. OptiMark (gadoversetamide- no longer on market)
3. Magnevist (gadopentetate dimeglumine)
\*higher doses and multiple doses are thought to increase the risk\*
117
What GBCM are the safest in regard to NSF?
1. MultiHance (gadobenate dimeglumine)
2. Gadavist (gadobutrol)
3. Dotarem (gadoterate meglumine)
4. ProHance (gadoteriodol)
Eovist (Gadoxetate disodium) is newer with limited information with regard to NSF
118
Patient factors at higher risk to NSF?
Possible mechanism?
1. Metabolic acidosis or drugs that increase risk to acidosis
2. High Iron, calcium and or phosphate levels
3. high dose erythropoietin
4. immunosuppression
5. vasculopathy
6. an acute pro-inflammatory event
7. infection
\*\*no good relationship though\*\*
_Transmetallation_: another ion replaces and displaces the toxic gadolinium ion (thought because of higher stability within the safer GBCM)
119
What three high-risk GBCM are contraindicated by the GDA when the GFR is \<30?
1. Omniscan (gadodiamide)
2. OptiMark (gadoversetamide)
3. Magnevist (gadopentetate dimeglumine)
120
Where is GBCM retained in the body?
Skeleton
Dentate nucleus and globus pallidus
\*\*greater with linear nonionic than macrocyclic agents\*\*
121
Contrast reaction immediate response?
1. See the patient
2. Discuss the reason for the imaging study
3. Description of the patient's current symptoms
4. Summary of patient's health problems and medications
5. Vital signs promptly
6. IV access secured
7. Pulse oximeter should be avaliable
8. Oxygen given at high doses
9. Examination
122
Contrast reaction physical exam?
1. level of patient consciousness
2. appearance of the skin
3. Quality of phonation
4. presence or absence of respiratory or cardiovascular symptoms
should monitor patient until symptoms have improved
123
Hives treatment?
* No treatment is needed in most cases
* If symptomatic, administer Benadryl 25-50 mg orally, IM or IV
* Alternative is Allegra (fexofenadine) 180 mg po
124
Diffuse erythema treatment?
* Preserve IV access, monitor vitals and use a pulse ox
* Give 0xygen, 6-10 L/min (via mask)
* If normotensive, no further treatment (antihistamines should be administed with caustion because they can worsen or exacerbate developing hypotension)
* If hypotensive, give 1 L of IV fluids rapidly (either 0.9% normal saline or LR)
* If hypotension is profound or does not respond to fluids, consider epinephrine (1:10,000) 1 mL (0.1 mg) slowly into a running infusion of IV fluids. Repeat as needed at 5-10 minute intervals up to 10 mL total. In the absence of IV access, consider epinephrine IM (1:1000), 0.3 mL (0.3 mg), or IM EpiPen or equivalent (0.3 mL, 1:1000 dilution fixed). IM epinephrine may be repeated up to 1 mg total
* Consider calling an emergency response team or 911 based on the severity of the reaction and the completeness of the patient response to treatment
125
Laryngeal Edema treatment?
* Preserve IV access, monitor vitals and use a pulse ox
* Give 0xygen, 6-10 L/min (via mask)
* Give epinephrine IM (1:1000), 0.3 mL (0.3 mg), or IM EpiPen or equivalent (0.3 mL, 1:1000 dilution fixed). IM epinephrine may be repeated up to 1 mg total, OR, espeically if the patient is hypotensive, give epinephrine (1:10,000) 1 mL (0.1 mg) slowly into a running infusion of IV fluids.
* Consider calling an emergency response team or 911 based on the severity of the reaction and the completeness of the patient response to treatment
126
Bronchospasm treatment?
* Preserve IV access, monitor vitals and use a pulse ox
* Give 0xygen, 6-10 L/min (via mask)
* Use a beta-agonist inhaler albuterol, 2 puffs (90mcg per puff), can repeat up to three times. In cases where bronchospasm is severe and/or unrepsonsive to inhaler, consider adding epinephrine IM (1:1000), 0.3 mL (0.3 mg), or IM EpiPen or equivalent (0.3 mL, 1:1000 dilution fixed), or epinephrine IV (1:10,000) 1 mL (0.1 mg) slowly into a running infusion of IV fluids.
* IM epinephrine may be repeated up to 1 mg maximum dose
* Consider calling an emergency response team or 911 based on the completeness of the patient response to treatment
127
Hypotension with bradycardia (pulse \< 60 bpm) treatment?
Vasovagal reaction
* If mild, no additional treatment is usually needed beyond the basic treatment for hypotension
* If severe (patient is unrepsonsive to above measures), give atropine 0.6- 1.0 mg IV into a running infusion of IV fluids (note that lower doses of atropine may exacerbate bradycardia)
* May repeat up to a total dose of 3 mg
* Consider calling an emergency response team or 911
128
Hypotension, Any cause (systolic pressure \<90 mmHg) treatment
* Preserve IV access, monitor vitals and use a pulse ox
* Elevate legs at least 60 degrees (Trendelenburg position)
* Give 0xygen, 6-10 L/min (via mask)
* Consider rapid administration of 1 L of IV fluids, 0.9% NS or LR
129
Hypotension with tachycardia (pulse \>100 bmp)
Allergic Like Reaction
* Preserve IV access, monitor vitals and use a pulse ox
* Elevate legs
* Give 0xygen, 6-10 L/min (via mask)
* give IV fluids
* If hypotension persists after the basic treatment of hypotension, give epinephrine IV (1:10,000) 1 mL (0.1 mg) slowly into a running infusion of IV fluids. Can repeat as needed up to 10 mL (1 mg) total. Alternative, IM epinephrine (1:1000) could be give, 0.3 mL (0.3 mg) or IM EpiPen or equivalent (0.3 mL, 1:1000 dilution fixed).
* IM epinephrine may be repeated up to 1 mg maximum dose
* Consider calling an emergency response team or 911 based on the severity of the reaction and the completeness of the patient response to treatment
130
Unresponsive and pulseless treatment?
* Check for reponsiveness
* Activate emergency response team or call 911
* Perform CPR per American Heart Association protocols
* defibrillate as indicated if equipment is avaliable
* May administer epinephrine IV (1,10,000), 10 mL (1 mg) between 2 min cycles of CPR
131
Reaction Rebound Prevention
* IV corticosteroids are not useful in acute treatment of any reaction
* However, IV corticosteroids help prevent a short-term recurrence of an allergic-like reaction and may be considered for a patient having a severe allergic-like reaction before transportation to the emergency department
* Give hydrocortisone, 5 mg/kg IV over 1-2 minutes or methylprednisolone 1 mg/kg/IV over 1-2 minutes
132
Pediatric Dosing for isotonic fluid?
Isotonic fluid: 10 - 20 mL/kg or 0.9% normal saline or LR up to a maximum of 500 -1000 mL
133
Pediatric dose of Benadryl?
1 mg/kg up to a maximum of 50 mg
134
Beta agonist inhaler pediatric dose?
Albuterol 2 puffs (90 mcg/puff) for a total of 180 mcg - can repeat up to 3 times
135
Pediatric dosing of IM Epinephrine?
IM dosing: up to 30 kg - EpiPen Jr (0.15 mg)
IM dosing over 30 kg: use adult autoinjector, or 0.01 mL/kg (0.01 mg/kg) of 1:1000 dilution (maximum single dose of 0.3 mL (0.3 mg)) repeated every 5-15 minutes as needed up to a maximum dose of 1 mg (1 mL)
136
Pediatric dosing of IV epi?
IV dosing: 0.1 mL/kg of 1:10,000 dilution (0.01 mg/kg) maximum single dose of 1 mL (0.1 mg)), repeated every 5-15 minutes as needed up to a maximum dose of 1 mg (1 mL)
137
Who maintains editorial control over CPT codes? What does CPT stand for?
CPT= Current Procedural Terminology
The CPT Editorial Panel, appointed by the American Medical Association (AMA) Board of Trustees maintains full editorial control over code set develpment and maintenance
138
What is the next step after CPT codes are approved?
They are evaluated using the Resource Based Relative Value Scale (RBRVS) methodology by the AMAs RBRVS Update Committee (RUC)
They make reommendations to CMS (Centers for Medicare and Medicade Services) on Relative Value Unit (RVU) assignments
CMS usually accepts the AMAs RUC recommendations in more than 90% of cases with minor geographic cost adjustements, they are multipled by an annual conversion factor to determine CMS payments under the Medicare Physician Fee Schedule
139
What is included in an RVU?
1. Encounter time, intensity, effort and skill (work RVU)
2. Costs of maintaining a practice with equipment, supplies, and non physician staff (practice expense RVU)
3. Professional liability expenses (the malpractice RVU)
140
What is medical necessity?
"healthcare services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms that meets accepted standards of practice."
Usually won't pay for a study unless this is met (private insurance or CMS)
Practiaility- pre-approved diagnosis code must match a CPT service code at time of claim is submitted to a payer
141
Who creates the diagnosis codes?
International Classification of Diseases (ICD) system, established by the World Health Organization, currently is in its 10th revision (ICD-10) which describes the signs, symptoms or specific diagnosis of a patient that form the indication for a healthcare serice.
"rule out" or "consistent with" do not count
142
Primary organization that credientials professional medical imaging coders?
Radiology Coding Certification Board
- extract ICD 10 info from radiology reports and asign CPT codes based on specific details of described services
Structured templates help radiologists comply with many of these reporting requirements
143
What is the False Claims Act?
Protects the government from false claims. A false claim ruiling can result in fines up to 3x the billed amount plus 11,000 per claim filed because each single exam or service billed counts as a claim
144
HIPPA protection of identifiable health information (PHI)- who reinforces it?
Within the US Department of Health and Human Services, the Office for Civil Rights (OCR) has responsibility for enforcing these rules with civil money penalties
145
Definition of PHI
1. Names
2. Geographic Subdivisions smaller than a state (except for the first three digits of a ZIP code representing a population of greater than 20,000 people)
3. All elements of dates (except year) related to an individual, such as birthdate, admission date, discharge date, and date of death
4. Phone numbers
5. Fax numbers
6. email addresses
7. Social Security numbers
8. Medical Record numbers
9. Health Plan Beneficiary Numbers
10. Account numbers
11. Certificate and license numbers
12. Vehicle identification and license plate numbers
13. Device identifiers and serial numbers
14. Webpage universal resource locators (URLs)
15. Internet protocol (IP) addresses
16. Biometric identifiers such as finger or voice print
17. Full face or similar photograph
18. Any other unique identifier, characteristic or code
146
PHI disclosure exceptions
1. delivery of care or treatment
2. payment activites
3. Healthcare operations involving quality or competency assurance, fraud or abuse detection or compliance
when required by law, can be released to
1. public health authorities
2. during an investigation of abuse, neglect or domestic violence
3. to oversight agencies
4. judicial and administrative proceedings
5. law enforcement purposes
6. for work's compensation
147
Nuremberg Code definition?
First international codification of minimal expectations for the condult of ethical research involving human subjects
\*\*experiments involving human subjects hsould only occur when the subject has freely chosen to participate and in the context of a clear scientific rationale\*
148
What was the Declaration of Helsinki?
Cornerstone of human research ethics, has recommended that all research protocols be reviewed by an independent committee prior to initiation
149
What is an IRB and what does it do?
Insitutional Review Board- has the authority to approve, deny, quire modifications in order to secure approval any proposed research protocol.
IRB is required to "diversity of members including consideration of race, gender, cultural backgrounds, and sensitivity to such issues as community attitudes" and to register with the Department of Health and Human Services (HHS)
150
Consent process for research
1. provide adequate info about the 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 subjects comprehends all necessary information
5. Obtaining the subject's voluntary agreement to participate
6. Providing ongoing information as the subject or situation so requires
\*can be waived if no more than minimal risk to the participants and cannot be pratically carried out without a waiver.
\*exemption from formal protocol review when a project consitutes a QI activity, as long as the primary objective is to improve local practice rather than to create generalizable knowledge. IRB approval is also not needed if it doesn't meet criteria of human subjects research (i.e. studies that utalize open source public database)
151
How many radiologists are named in a malpractice lawsuit each year? what i the average payment?
7%
480,000
The average radiologist spends approximately 19 month sof his or her career with unresolved or open malpractice claim
152
What is the most common type of malpractice insurance coverage?
"Claims-made" policies are the MC and protect physicians from personal finanacial liability, up to a predetermined policy cap but only why the policy is in effect.
- Physicians usually need to arrage for tail insurance when changing jobs or retiring to ensure continued financial protection
153
What is an occurence malpractice policy?
Policy that will cover any claim for an event even if it is filled after the policy lapses
154
Tort of Negligence of medical malpractice?
1. Physician must have an essential duty to a patient
2. There must be a breach of duty, failure to meet the standard of care. SOC varies by jurisdicition but is reasonable, prudent or ordinary physician of a similar specialty would have acted in a similar circumstance.
3. Causation must exist. The breach must have been the proximate cause of injuries.
4. The negligence must result in damages. In many jurisdictions, emotional distress, pain and suffering are frequently considered remunerative damages.
155
Most common types of claims against radiologists?
1. Diagnostic Errors- MC
2. Procedural complications
3. Communication Deficiencies
156
Hindisight bias
Tendency for people with a knowledge of the actual outome of a case to believe falsely that they would have predicted its outcome
157
Negligent diagnosis claims can be categorized as?
1. Failures of perceptions (not identifying the finding)
2. Failures of interpretation (i.e. identifying the finding but not appropriately appreciating or adequately communicating its significance)
3. Combo of both
OR
1. Cognitive Errors (not identifying a nodule on a chest radiograph) which are erros of visual perfection (scanning, recognition and interpretation)
2. System errors (failure to adequarely communicate the nodule to the doctor), health system issues or context of care delivery problems
158
Reasons why you might have a malpractice suit about procedures?
The doctor did not
1. minimize the risk of the complication
2. identify the complication once it occured
3. treat the complication
\*\*Recommend full disclosure about any untoward events, and ongoing communication- also detailed and contemporaenous documentation of events, discussions and rationale for decisions in radiology report or elsewhere is also helpful in court
159
Clinical Situations that warrant nonroutine communication?
1. Findings that warrant immediate or urgent intervetion
* "critical result"= any result or finidng that may be considered life threatening or could result in severe morbidity and require urgent or emergent clinical attention"- within 60 minutes of the time the obervation is made
2. 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
* ex new or unexpected finding that could result in mortality or significant mortality if not treated in a timely manner
* Communication with 12 hours
* ex. impending hip fracture or intrabdominal abscess
* those findings that are not time sensitive but mechanisms must be in place to ensure delivery of important findings may be reported electronically when electronic messaging mechanisms are in place
These shoudl all include the date, time of the communication, the person reporting and the person recieving the information and what info was conveyed.
160
What is a DICOM?
Digital Imaging and Communications in Medicine (DICOM)
International standard that specifies protocols for display, transfer, storage and processing of medical images
Applies to storage of pixel-based image data and metadata
Meta-data= information within the "DICOM header" including information about the image, series, exam, patient, imaging facility and scanner
161
What does the DICOM allow?
Allows data to be organized, queried, retrieved and tramsitted between systems in an organized fashion
Allows information about an order to be transmitted between the radiology information system (RIS) and the modality (CT, MR, or ultrasound machine) rather than having to be manually entered by the technologist and risk incorrect entry
Standard DICOM data elements are required to contain specific information while private data elements can be defined by the vendor. To enable interoperability between systems, vendors who implement products that use DICOM are expected to provide customers with conformance standards that detail their use of the DICOM standard.
162
What is HL7?
International standards organizaton responsible for developing and maintaining standards for the exchange, integration, sharing and retrieval of medical image (i.e. nonimage data)
HL7 V2 messaging standard is generally considered to be the most widely implemented healthcare-related standard in the world. Text-based standard facilitates the exchange of medical data by enabling interoperability between many types of electronic medical systems that need to communication.
HL7 V3- less adoptive because of increased complexity
Newer HL7 Fast Healthcare Interoperability Resources (FHIR) standard allows software developers to use internet transactions to exchange medical data between systems, increasing the potential for data exchange between systems
163
What are Ontologies?
Formal collections of terms and their inherited or causal relationships.
RadLex is the largest radiology-specific lexicon containing more than 68,000 terms that describe imaging anatomy, procedures and pathology
RadLex Playbook, special portion of RadLex, defines standard imaging exam names, descriptions, and codes--\> now merged with LOINC (Logical Obervation Identifiers Names and Coes), the international standard nomeclature for health measurements, observations and documents
164
PACS- what does it stand for? what is it?
Picture Archiving and Communications System
Radiologist's primary tool for imaging viewin and interpretation. Workstation, display, short-term storage and long-term archive.
Communicates with DICOM transactions, and with the RIS and/or EMR using HL7 transactions that are translated to and from DICOM.
Now can be entirely web-based an accessible on mobile devises as well as desktop thin clients
165
What is VNA?
Vendor-Neutral-Archive (VNA)
Allows data to be stored in a central archive that may support viewers for multiple types of DICOM images (radiology, cardiology, operating rools) as well as for non-DICOM data (photos and pathology)
Enterprise imaging relies heavily on VNA technology to facilitate dissemination, viewing and storage of medial imaging data beyond radiology.
Determining how best to format and exchange the metadata (patient info, body part, date of acquisition) accompanying a non-DICOM image is a major challenge in enterprise imaging
166
What is the RIS?
Radiology Information System
Software application that manages all aspects of an imaging examination, including order reconcilitation, patient scheduling and tracking, communication with modalities and PACS, reporting, results notification and billing
May be a standalone application or a part of the EMR application
167
What are the requirements for ambient light?
ACR-AAPM-SIIM technical standard recommends that ideal reading room ambient light fall in the range of 25-50 lux
168
What is the maximum gray value luminance for diagnostic monitors?
350 cd/m2 for nonmammographic interpretation and
420 cd/m2 for mammographic interpretation
(reference, top flat screen TV have a peak luminance of upwards of 400 cd/m2)
169
What is Lossless versus Lossy compression?
Compression is used to decreased image file size to speed up transfer and decrease storage requirements
_Lossless compression -_ decreasing redundant information (i.e. black background of a CT image)- content is preserved and can only reduce file size by 3:1
_Lossy compression-_ more susbtaintal image size compression (10:1) by irreversibly discarding unnecessary or minimally important image information without significantly compromising diagnostic quality
170
Common radiology injuries?
Carpal Tunnel= dorsiflexion of the wrist from upward angulation while typing
Cubital tunnel syndrome= repetative strain injury (RSI) at the elbow or wrist
DeQuervain tenosynovitis- secondary to RIS at the thumb
Need neutral body position with the forearm, wriswt and hand parallel to the floor, lumbar support and appropriate distance between the user and the display
171
Describe work flow from order to report
Order placed in eMR --\> HL7 transations communicate to RIS --\> RIS communicates order to relevant modality via the DICOM Modality work List --\> communicates with PACS via DICOM
Radiology vies on PACS and dictate the report--\> reporting software sends report to the RIS and EMR via HL7 transactions
172
What are Downtime Procedures?
Include:
_Disaster Recovery_
* direct activities followed in the event of a disaster (off site data back up, frequency of backup cycles and steps requried to restore critical data)
_Buisness Continuity_
* Necessary systemic precautions and backups required to continue to care for patients when a system failure (such as a power outage) occurs under otherwise routine working conditions
173
What are the number of nines of a high-avaliability system?
PACS is expected to perform at 4-9s- 99.99% uptime
(no more than 50 minutes of downtime a year)
Fault tolerance - ability of a system to continue to function if one of its components fails (redunancy is built into the system)
174
What imaging modality is considered PHI?
Imaging of the face because contours can be reconstructed from CT or MRI imaging of the head
175
De-identification versys anonymization?
De-identification involves removing PHI from the imgaging examination such that the identity of the patient cannot be determined base on the information contained in the images or the metadata-- but they maycontain information that would allow somoeone to identify the patient with a "key"
Anonymization- removing all PHI and other identifiable data from an imaging examination such that the identify of the patient cannot be revealed
176
What is imaging segmentation?
Postprocessing technique
Isolating or extracting a region of interest from an image or extracting a subset of images from an image stack for further analysis
(e.x. segmenting gray and white matter in the brain)
177
What is image registration?
Post processing technique
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 deformations 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 accomadate changes in patient positioning, lung expansion or soft tissue shape changes in aligning image sets.
178
What is AI? What is Machine Learning?
AI- field of computer sicence that gives computers the ability to mimic human intelligence
Machine Learning- subfield of AI that enables computers to learn a task without being given an explicit set of instructions.
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.
_Challenges:_
1. understanding the "black box" model works
2. ensuring that the model performs reliably in all potential applied settings and conditions,
3. and efficiently integrating the model into clinical workflow
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What are tiered huddles?
_Huddle=_ brief structured meeting occuring in an organizational unit in which participants reiew what has recently occured, the status of the unit and what is anticipated in th enear future.
First-tier huddles are held within local units and inovlce all frontline staff on a service for the day
Unit leaders then attend huddles at a higher tier, whose leaders then attend hueddles at a higher tier--\> up the executive team
Take place at a visibility board which tracks important elements of the daily management huddles for all staff members to see
180
What is a Daily Readiness Assessement?
Reviewed at the huddle and helps staff be aware of the number and types of patients to be seen that day and to determine whether they are prepared to accomodate their needs
Topics include:
1) methods: ensuring that the proper protocols and plans are in place to accommodate patients, epsecially those with special needs
2) equipment: reviewing wehter all the equipment is operation and staff have appriopriate training
3) Supplies
4) Associates
181
Problem management and accountability cycle in Daily Management System?
Continuous problem solving- staff are enouraged to identify problems at the huddle and document them on the visibilit y board with an "owner" of the problem and expected resolution date
Regular followup of daily huddles, along with traching of assignments on the visibility board helps provide a mechanism to follow up on assignments and imrpoves the chance that they will be resolved.
One must see what is happening in the workplace to truly understand it. Managers and leaders are encouraged to minimize the time spent in closed-door meetings in favor of spending time where the work is done. They are to observe and ask questions.
182
Steps in a Project-Based Improvement Method
1_. Identify a problem_
- something that is difficult to deal with with or something to be worked out and solved
_2. Forming a Team_
- Project sponsor, Project Leader, Project Participants (volunteers), Project Coach
_3. Assessing Current Performance_
_4. Measuring Performance_
- end-outcomes, intermediate outcomes, process measures
- run chart
_5. Establishing a Specific Goal_
- SMART: Specific, measurable, achievable, relevant and time-bound
- Goal should state beginning performance, the end performance and the date
_6. Identifying Causes of Problems_
- identify causes of the problem (cause-and-effect diagram or fisbhone diagram)
_7. Prioritizing Problem-Solving Efforts_
- After finding the possible causes, the frequency of those causes should be measured in some way- often with a Pareto chart
_8. Developing Solutions through Iterative Testing_
- Plan-Do-Study-Act (PDSA cycle)
- need to improve performance, so it is important to monitor performance throughout the life of a project
- multiple PDSA projects are needed for most projects
_9. Sustaining the Improvement_
- 1) establish regular measurement and feedback
- 2) use handoffs to enforce standards by ensuring that all staff expect the same standard
- 3) establish the practice of stopping the process and summoning immediate supervisors when a problem is encountered
- 4) embedding checks into the process
- 5) using high-reliability solutions
_10. High-reliability Solutions_
Processes that rely on education and feedback tend to result in lower consistency than those that rely on standardization of procedures - which in turn result in lower consistency of outcome than those that rely on changes to infrastructure and organizaton culture
- High-reliability process changes are more effective and require less effort by the process owner to sustain than low-reliability solutions
183
What is a Run chart?
Run chart displays data over time
Should display the mean before the beginning of the project and at the end of the project as well as the performance goal
Annotated run chart- run chart that also indicates the data nd nature of interventions implemented during the project
184
What is the Pareto Principle and what is a Pareto chart?
Pareto principle- known as the 80-20 rule states that a few causes are usually responsible for the majority of problems
Pareto chart- illustrates which causes occur most frequently
185
What is a Fishbone diagram used for?
Cause-and- effect diagram
186
QI project definition
"a temporary group activity, designed to produce a unique product, service, or result."
"
187
What is project management and what are 4 comonents of effective project management?
Project management - "application of knowledge, skills and techniques to execute projects effectively and efficiently"
1. Task management
2. Progress tracking
3. Conducting effective meetins
4. Avoiding mistakes common to QI
188
Preprocedural Care Patient Identifiers- How many are needed and what can be used?
At least 2 patient identifiers:
* Patient Name
* Assigned identification number
* Telephone number
* other person specific identifier (date of birth, government-issued photo identification and last 4 of social security number)
NO: Patient location or room number
Identfier- patient, relative, guardia, domestic partner, healthcare provider who has previously identified the patient
189
Things to assess prior to sedation?
* Recent oral intake
* recent illness
* pulmonary status (upper airway especially)
* cardiac status
* baseline vital signs
* level of consicousness
* pulse oximetry
* Capnography
* Electrocardiography
190
How do you define minimal sedation?
A drug-induced state, created by the administration of medications to reduce anxiety, during which the patient responds to verbal commands. In this state, cognitive funciton and coordination may be impaired, but ventilatory and cardiovascular function are unaffected
191
How do you define moderate sedation/anagesia?
Minimally depressed level of consciousness, induced by the administration of pharmacologic agents, in which the patient retains a continuous and independent ability to maintain protective reflexes and a patent airway and to be aroused by physical or verbal stimulation
192
How do you define deep sedation/analgesia?
A drug-induced depression of consciousness during which the patient cannot be easily aroused but responds purposefully after repeated or painful stimulation. Indepenedent ventilatory function may be impaired. The patient may required assistance in maintaining a patent airway. Cardiovascular function is usually maintained.
193
Define General Anesthesia
A controlled state of unconsciousness in which there is complete loss of protective reflexes, including the ability to maintain a patent airway independently and to respond appropriately to painful stimulation
194
Screening you must do to give sedation without anesthesia?
* congenital or acquired abnormalities of the airway
* liver failure
* lung disease
* congestive heart failure
* symptomatic brain stem dysfunction
* apnea or hypotonia
* history of adverse events with anesthesia
* morbid obesity
* severe GERD
* ASA status as well
\*\*need a healthcare professoinal whose sole focus is to monitor the patient, the patient must have IV access, continuous monitoring should include (consciousness, RR, pulse ox, blood pressure, HR, and cardiac rhythm)
\*\*supervising physician should have knowledge of the pharmacology, indications, and contraindications for the use of sedative agents and reversal drugs (which may be transient)-- need to monitor after sedation for 2 hours prior to discharge!
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What are the ASA physical status classification levels?
Class I- normal healthy patient
Class II- a patient with a mild systemic disease
Class III- a patient with severe systemic disease
Class IV- a patient with a disease that is a constant threat to life
Class V- a moribund patient who is not expected to survive without the procedure
Class VI- a declared brain-dead patient whose organs are being removed for donor purposes
III + IV may require anesthesiology; class V need anesthesiology
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Elements of Informed consent (6)?
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 resonable alternatives to the proposed procedure
6. The right to decline the proposed procedure
\*\*exception- delay in treatment would jeopardize the health of a patient who is unable to provide informed consent
\*\*can be a videotape, note in the chart, or other permenant modality
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Who can give consent?
1. Patient's appointed healthcare representative, legal guardian or appropriate family member
In emergency situation when the patient needs immediate care, the patient's predetermined wishes are not known or appropriately documented and consent cannot be obtained from the patient's representative, the physician may provide treatment or perform a procedure "to prevent serious disability or death or to alleviate great pain or suffering"
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What about minor consent?
States and courts have never allowed children \<12 years to make medical decisions and exercise self-determination; whereas, adolescents between ages 12-18 (or 19 in some states) experience a gradual transition to self-determination (based on state) and below factors:
1. Legal determination of maturity (married status, parenthood, self-sufficiency or active duty in the military)
2. Evidence that the child is sufficiency mature to make his or her own decisions (age \>14 years, evidence that they can understand implications including risks, benefits, long and short term consequesnces and alternatives and no coercion)
3. Conditions exempting parental consent (seeking testing or treatment for STDs or contraception, prenatal care, abortion,mental health treatment, emergency care ot treatment of alcohol or drug abuse after age 12)
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What is Universal Protocol?
1. Preprocedure Verification
- all information and relevant equipment are present and correctly labeled, identified, and matched to patient's identifiers and reviewed prior to procedure start time
2. Marking of the procedure site
- If there is more than one possible location, it should be marked. Practitioner who is present at time of procedure. At or near the procedure site and should be visible after skin prep and draping
3. Procedure Time Out
Involve the members of the team- all relevant members actively communicate and agree on: correct patient identiy, correct site, and procedure to be done
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When do you wash your hands instead of using hand sanitizer?
Hands are visibly dirty, before eating, after using the restroom, or after known exposure to C diff, norovirus or Bacillus Anthracis
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When do you use hand hyiene?
1. Before eating
2. Before and after having direct contact with a patient's skin
3. After contact with blood, body fluids or excretions, mucous membranes, nonintact skin or wound dressings
4. After contact with inanimate objects in the immediate vicinity of the patient
5. if hands will be moving from a contaminated body site to a clean body site during patient care
6. after glove removal
7. after using the restroom
soap and water for at least 15 seconds
alcohol product should cover all surfaces of the hand and should take 20 seconds
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What are active and latent errors in root cause analysis?
RCA: structured method used to analyze serious adverse events to decrease likelihood of recurrence- identify both active and latent errors
Active errors: errors occuring at the point of interface between humans and a complex system (ex. nurse gives full dose heparin rather than a heparin flush)
Latent errors: the hidden problems within healthcare systems that increase the likelihood of an adverse event n(ex. latent condition is the fact that the two vias appeared identical and both are routinely stocked near each other in the same cabinet)
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How does a RCA work?
1. data collection to create an objective narrative of the event based on a review of the medical record and interviews with people involved
2. Multidisciplinary team analyzes the sequence of events leading to the error, with the goals of identifying how the event occured (active errors) and underlying conditions that contributed to the event (latent error)
Serious adverse events are almost never the rsult of a single cause and usually ahve a lot of contributing factors
3. Culminate in an analysis of issues that should be addressed to decrease the likelihood of recurrence and plan for addressing those issues (including a timeline and individual responsibility)
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How many bits are in a byte?
8 bits in 1 byte
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How many bytes are needed to represent shades of grey?
2^8 = 256 shades of grey
1 byte is needed
- each bit in an 8 bit byte can "be" one of two things (0 or 1)
- 2^8 represents the total number of combos of zeros and ones you can get in a single byte= different shades of grey
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How do you calculate an image file size?
Image file size - matrix size (rows and columns) x # 8 bit bytes required to represent image depth
Ex. CT slice 512 x 512 with 16 bit greyscale
512x 512x 2 = 524,288 (~0.5 MB)
of note, a CXR is ~10 MB
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How long must images be stored?
5-7 years or longer
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