Requesting Imaging Examinations Sue Coull Quality & Safety Manager Imaging & Nuclear Medicine Departments

Why do this session? This year we have had: 6 reportable incidents to the CQC due to : 6 reportable incidents to the CQC due to : - wrong patient referred (wrong details on form) - wrong examination requested 8 near misses between July-Oct (specific audit) 8 near misses between July-Oct (specific audit) Metformin related SI (patient death) – information not on form Metformin related SI (patient death) – information not on form Lung drain related SI (patient death) – anticoagulants not on form Lung drain related SI (patient death) – anticoagulants not on form

Just another test? NO!, not the same as other tests NO!, not the same as other tests Risks to patient include: Risks to patient include: - inducing cancer from exposing patient to harmful radiation (excl MRI and U/S) - contrast induced nephropathy (if metformin not stopped) - bleeding (complication from interventional procedures)

Ionising Radiation - risks Ionising radiation is radiation that consists of small packets of energy Ionising radiation is radiation that consists of small packets of energy –x-rays, gamma rays, beta particles, alpha particles As this energy enters a cell it can cause damage to the DNA which can kill it or cause it to mutate. As this energy enters a cell it can cause damage to the DNA which can kill it or cause it to mutate.

Ionising Radiation - Effects Damage depends on Damage depends on –how much radiation –type of radiation –how quickly it is delivered –where the energy is deposited Repair can occur Repair can occur For diagnostic imaging - probability of an effect occurring – stochastic effect For diagnostic imaging - probability of an effect occurring – stochastic effect

Ionising Radiation - Effects For a dose of 1 mSv, there is a 1 in 20,000 chance of inducing a cancer (5% per Sievert) For a dose of 1 mSv, there is a 1 in 20,000 chance of inducing a cancer (5% per Sievert) CT delivers one of the highest doses CT delivers one of the highest doses Some CT examinations (chest/abdomen/pelvis) can give 15 mSv - a 1 in 1300 chance of inducing a cancer. Some CT examinations (chest/abdomen/pelvis) can give 15 mSv - a 1 in 1300 chance of inducing a cancer. At RSCH we do chest/abdo/pelvis scans a year so we might well be giving two or three of our patients a cancer every year At RSCH we do chest/abdo/pelvis scans a year so we might well be giving two or three of our patients a cancer every year

Injury to shoulder from percutaneous transluminal coronary angioplasty

Injuries to back and arm from multiple prolonged electrophysiological and ablation procedures with bi-plane fluoroscopy. Wounds on back healed into scarred areas while injury on arm required grafting.

Injury following three procedures involving transjugular intrahepatic portosystemic shunt placement, demonstrating disfigurement after surgical correction.

Justification under IR(ME)R Very important that: correct and relevant information is provided regarding the patient so that... correct and relevant information is provided regarding the patient so that... the examination can be ‘justified’ to proceed (legal requirement under (Ionising Radiation (Medical Exposure) Regulations (IR(ME)R) the examination can be ‘justified’ to proceed (legal requirement under (Ionising Radiation (Medical Exposure) Regulations (IR(ME)R) - do the benefits outweigh the risks? - do the benefits outweigh the risks?

Incidents under IR(ME)R Statutory requirement that all ‘unintended’ and ‘much greater than intended’ doses of radiation are investigated and reported to the Care Quality Commission Reported via DATIX and directly to CQC. Senior Trust Managers including Chief Exec have to be informed when reporting externally.

Other risks : Contrast Induced Nephropathy Severe contrast induced nephropathy is a rare complication following the use of X- ray contrast medium. Severe contrast induced nephropathy is a rare complication following the use of X- ray contrast medium. The incidence can be reduced by identifying those patients most at risk and ensuring that they are adequately hydrated at the time of the scan/angiography/intravenous urography. The incidence can be reduced by identifying those patients most at risk and ensuring that they are adequately hydrated at the time of the scan/angiography/intravenous urography.

Other risks : Contrast Induced Nephropathy For any intra-vascular contrast enhanced CT scan, angiography and intravenous urography the following risk factors MUST be highlighted on the referral form: For any intra-vascular contrast enhanced CT scan, angiography and intravenous urography the following risk factors MUST be highlighted on the referral form: Known renal impairment (eGFR <60ml/min) Known renal impairment (eGFR <60ml/min) History of renal disease or renal surgery History of renal disease or renal surgery Multiple myeloma Multiple myeloma Diabetes mellitus Diabetes mellitus Patients taking metformin Patients taking metformin

Other risks : Contrast Induced Nephropathy If the eGFR is known to be <60, please enter the result and the date of the test. If the eGFR is known to be <60, please enter the result and the date of the test. In addition, if any of these risk factors are present an eGFR from the 4 weeks preceding the test must be available. In addition, if any of these risk factors are present an eGFR from the 4 weeks preceding the test must be available.Metformin: Any patient with an eGFR <60ml/min taking metformin should be told to stop taking it on the day of the scan/angiography and for 2 days afterwards Any patient with an eGFR <60ml/min taking metformin should be told to stop taking it on the day of the scan/angiography and for 2 days afterwards

Other risks: Bleeding from interventional procedures Referral form must state anti-coagulation medication the patient may be on Referral form must state anti-coagulation medication the patient may be on Discuss with radiologist Discuss with radiologist

So in conclusion… Please help by ensuring that you ask for the Right Test Right Test Right patient Right patient and provide Right information Right information ….and you will hopefully get the Right outcome