By: Chris Atherton, RN, BSN, MPA

On August 24, 2011, the Joint Commission issued a Sentinel Event Alert concerning radiation risks of diagnostic imaging. The Alert described the issues surrounding high or repeated dosing during diagnostic procedures such as CT, nuclear medicine and fluoroscopy. Risks associated with ionizing radiation in diagnostic imaging include cancer, burns and other injuries. Patients most at risk for harm are children and young adults, pregnant women, individuals with medical conditions sensitive to radiation such as diabetes mellitus and hyperthyroidism, and individuals receiving multiple doses over time. Not included in the Alert were issues surrounding therapeutic radiation or fluoroscopy.

So, you are asking, why should we be concerned? Invasive procedures in the EP lab are done under fluoroscopic guidance, so this Alert doesn’t apply to us. Or does it?

As care providers (physician or allied professional) we have an obligation to our patients to “do no harm.” When it comes to the use of radiation, we should keep in mind the acronym ALARA: As Low As Reasonably Achievable. The complex interventions that we perform in EP can sometimes deliver a high radiation dose to the patient’s skin and can cause serious skin injuries. In addition, the patients that we see in EP often have numerous radiologic interventions/testing within a short period of time that increase exposure dosages quickly. And, although the EP world is not currently identified in the Joint Commission statement, we should be “alerted” to the situation so we can become proactive.

What did our program do? As with any initiative, we reviewed the data and the current processes that we had in place. As a registered nurse, I am aware of my roles and responsibilities related to working in an environment with radiation. However, in this situation, I deferred to the specialists in my area — my radiologic technologists. As the director of the program, I rely on these staff members to educate and guide the medical and nursing staff through all issues related to imaging. I give all the credit to my RTRs for their diligence and hard work on this initiative. The following steps are part of the initiative that my department is taking to reduce unnecessary exposures:

• Participation in the newly-formed hospital task force on radiation exposure. Although EP was not included in the initial Alert, our department is participating in order to form a more cohesive approach to dosing. The ultimate goal of this task force is to develop appropriate protocols and procedures as well as formulate a process for cumulative dosing reporting for the patient. A form has been developed for internal departmental use that will assist us in tracking the patient dosages from an EP perspective.

• Increase awareness among physicians and other clinicians about the levels of radiation utilized in our procedures. We worked with our Clinical Infomatics department to automatically include dosing from each case on the physician’s dictated report. This dosing information is entered into the system post-procedure. All dosing is readily visible to the physician during the review and signing of procedural dictation.

• Create a patient education tool that outlines potential issues related to radiation dosing. Included in this tool will be signs and symptoms to look for as well as actions to take if any issues are noted. This tool will be reviewed during pre- and post-procedure education with the patient and family, and documented appropriately in the medical record.

• Identify maximum dosing for each type of study done within the department. It is important to adhere to these guidelines so that alerts can be formulated in a consistent basis.

• Employ dosing utilization guides to create alerts for the outpatient clinic, so the patient can be assessed at follow-up visits for potential harm. If the patient reaches an identified level, the clinic will be alerted. Appropriate documentation will be included in the clinic chart, which will indicate that the physician has assessed the patient and provided treatment for any adverse effects. Absence of injuries will also be noted. This is a technique that will “close the loop.” Not only are we addressing the issues of exposure, but we are assessing for any issues.

• Incorporate new technology in order to reduce and report exposure times. We recently purchased new fluoroscopy equipment, which included a reporting package that was free of charge for one year. We are able to set alert levels of fluoro time and radiation dosing for each procedure. Our system is monitored electronically by the manufacturer. If we reach pre-set levels, my RTRs will be alerted by email so appropriate action may be taken. In addition, our physicians are encouraged to use the lowest dose possible as well as alternative methods of imaging in order to reduce exposure times during complex procedures.

• Implement an education program for EP staff concerning radiation safety and the potential harm related to increased exposure/dosing. This will be done on an annual basis during competency verification.

Seeing the Alert was a good thing for us. It increased our awareness of the subject and forced us to become proactive. In the long run, it will mean better care for our patients. In addition, if and when the Joint Commission extends the definition of the alert, we will be ready. We have implemented actions that address the very issue that the Joint Commission is “alerting” us to!

Chris Atherton, RN, BSN, MPA is the Director of EP Services at Indiana University Health La Porte Hospital in La Porte, Indiana.