Part I (1-31) Flashcards
Page 1
Institute of Medicine’s Six Improvements
STEEEP Safety Timeliness Equity Efficiency Effectiveness Patient-Centeredness
Page 1
Limitations of Traditional QI Techniques in Healthcare
Static Physician focused Under-emphasizes - Non-MD contributions - Organizational processes
Page 1
Three major focuses of traditional older theory practice of QA
Measuring Performance
Comparing Performance to Standards
Improving Performance
- When Standards are not met
Page 1
QA is considered
FPPRR Finger Pointing Punitive Policing Reactive Retrospective
Page 1
QI is considered
Prospective and Retrospective
Avoids attributing blame
Creates Systems to prevent errors
Continuous Process
Page 2
Describe modern quality science
Discipline whereby statistical techniques are used to assist decision making regarding product quality and production pathways
Page 2
Describe the New Paradigmatic Approach to Quality Science (Redefined Quality in Healthcare)
Continuous effort by all members of an organization to meet the needs and expectations of patients and other customers, insurance companies, families, providers, and employees
Page 2
Six IOM Quality Aims
Safe Timely Effective Efficient Equitable Patient-centered (((STEEEP)))
Page 2
New Paradigmatic Approach to Quality Science
Three components
Measuring Quality
Improving Quality
Personnel Management
Page 2
Six Core Competencies of MOC
FISPPP Fund of Knowledge - Medical Interpersonal / Communication Skills System Based Practice Professionalism Patient Care - Compassionate - Appropriate - Effective Practice-based - Learning - Improvement
Page 3
Dashboard
A visual display of the most important information needed to achieve one or more objectives consolidated and arranged on a single screen.
Can be monitored at a glance
Page 3
Benchmarking
Measurement of an organizations quality compared with a standard of its peers
Page 3
Objectives of Benchmarking
- Determine what and where improvements are necessary
- Analyze how other organizations achieve high performance levels
- Use this information to improve performance
Page 3
What is a PDSA Cycle
A 4 step cycle - used for QI Plan Do Study Act
Page 4
Plan -
Identify an area of your practice judged to be in need of improvement and devise a measure to asses the degree of need
Page 4
Do -
Put the plan in action and take baseline measurements
Page 4
Study
Determine how well your measure compared to the desired goal
Page 5
Act -
Devise and implement a plan for performance improvement
- After your improvement plan implementation, begin another PDSA cycle
Page 5
Lean
- Organizational style of continuous improvement workflow
- Emerged from postwar Japan
- Toyota Production Systems (TPS)
- Emphasis on smoothness of workflow from end to end
- Best used for closing performance gaps
- Lean six sigma can be complimentary
Page 5
Two core management principles of Lean
- Relentless elimination of waste
- Respect for ppl with long term relationships
- methodology has a fundamental reliance on company culture
Page 5
Lean
- Forms of Waste
MOWIT DDSP Motion Overproduction Waiting Inventory Transportation Defective Steps Defective Products
Page 5
What focus is one reason Lean has become popular in healthcare quality improvement
Unnecessary Variation
Page 5
Potential stumbling block in implementation of Lean
Culture - Lean relies heavily on employee engagement
Page 6
Value Stream Mapping -
- Tool to help understand and improve the material and information flow within a process
- End product is a visual flow map
Page 6
What does the Five S Tool focus on?
- Standardization of work areas
- Eliminate clutter
- Find a place for everything
Page 6
What does Five S stand for?
Sorting Straightening Systematic Cleaning Standardizing Sustaining
Page 6
Pull Systems
Work to emulate one-piece flow
- the next step of work on an item
- occurs immediately at completion of prior step
Page 6
Kanbans
Alert systems that signal readiness for additional parts or work
Page 6
Error-proofing
Defining and standardizing process steps and quickly addressing new sources of error with further refinement of the steps
Page 6
In Lean systems what two primary issues result in ‘poor flow’
- Unreasonable work due to poor organization
- Pushing beyond natural limits
- Lean focuses on ‘system’ impositions on workers
Page 7
DMAIC
Design Measure Analyze Improve Control
Page 7
Six Sigma targets -
a defect rate of how many opportunities?
how many standard deviations from the population average?
- 3.4 million
- six
Page 7
Two steps involved in Target Identification
- Focus on process as objects of improvement
(85% of worker effectiveness is due to the system within which they work, not the individuals skill) - Eliminate unnecessary variation
Page 8
Key Performance Indicators
Measures selected to evaluate organizational success
- can be quality or financial measures
- ideally would be something amenable to reproducible measurement
- patient safety, quality of care, customer service, utilization, productivity
Page 8
Quality Improvement Tools
Established techniques/instruments used to improve a structure, process, and/or outcome measure
Page 8
Flowchart or Map
A schematic representation of an algorithm or a process
- first step toward understanding the inputs, steps, and outputs
Page 8
Name four things that flow charts are used for?
SCIOM clarify Steps and decision points Identify the complexity and variability clarify Outcome vs Process steps establish Measures for procedures within a process
Page 9
Simple Flowchart
High level diagram that describes/depicts an overall process from beginning to end
Page 9
Swim Lane Flowchart
Processes and decisions are grouped visually by placing them in lanes
- Longitudinal direction represents sequence of events
- Lateral divisions depicts what subprocess is performing that step
- Arrows between lanes represent information or material passed between subprocesses
Page 9
Value Stream Map
- used to analyze the flow of materials and information currently required to deliver a product or service to a consumer
- used to measure value-added and non value-added activities from end to end
Page 9
Spaghetti Diagram
A map of the path taken by a specific item as it travels down the value stream in an organization
Page 9
Check Sheets
- used to facilitate the collection and compilation of event data during a process
- used to count different types of defects like interruptions, rework, and other errors
Page 9
Cause and Effect Diagram
- logically organize possible causes for a specific problem or effect by graphically displaying them in increasing detail
- helps to identify root causes and ensures common understanding of the causes
Page 9
Name three things Cause and Effect Diagrams are used for
- Define and understand the causes of an outcome
- Graphically display the relationship of causes to the outcome
- Help identify improvement opportunities
Page 9
Run Charts / Trend Charts / Tie Series Plots
- used to show trent over time
- single point measurements can be misleading
- displaying data over time increases understanding of real performance
Page 9
Control Charts
- depict mean, median, upper, and lower control limits to aid in identification of process noise vs significant deviation worthy of attention
Page 10
Pareto Chart
- based on Pareto principle
- small number of process steps contribute to the majority of problems
- arranged in descending order w/ highest occurrences shown first
- uses a cumulative line to track percentages of each category which distinguishes the 20 % of items causing 80 % of the problem
Page 10
Brainstorming
- group creativity technique used to generate a large number of ideas
Page 10
Four things brainstorming is used for
- Identify all issues
- Understand and clarify the process
- Generate potential solutions or action plans
- Data collection issues
Page 10
Multi-Voting
- group exercise used to select highest priority items from a brainstorming list
- narrows a large list
- allows an item that is favored by all, but not the top choice of any to rise to the top
- Variations: sticking dots, weighted voting, multiple picking-out method (MPM)
Page 10
Nominal Group Technique (NGT)
- structured method for generating ideas and/or condensing them
- more formal and structured than basic brainstorming
- minimal dialogue
- effective for controversial issues
- every team member has equal say
Page 10
Two stages of Nominal Group Technique (NGT)
- Formalized brainstorming
2. Decision Making
Page 10
Prioritization Matrix
- used to achieve consensus about an issue
- ranks problems or issues
- prioritizes problems to work on first
Page 10
Voice of the Customer (VOC)
- market research technique
- process to capture customers’ requirements
- produces a detailed set of customer wants and needs
- generally conducted at the start of a new product, process, or service
- used to better understand the customer’s wants and needs
Page 10
Walk-through
- simulates the processes a patient encounters during their visit
- can substantiate or validate survey findings
- identify bottlenecks
- provides direct knowledge of the patient experience
Page 11
National Patient Safety Goals
Established by the Joint Commission in 2002
- Help organizations address specific areas of concern for patient safety
- Highlight problem areas and describe evidence based solutions
- First set of NPSGs was effective Jan 1, 2003
- Examples - falls, patient ID, Infections, pressure ulcers, communication
- also created a list of ‘do not use’ abbreviations
Page 11
Who develops NPSGs?
Patient Safety Advisory Group
- composed or expert physicians, nurses, pharmacists, engineers, risk managers, and others with real world patient safety experience
Page 12
Give examples of key NPSGs involving radiology practice
- Two patient identifiers when providing care
- Report critical results on a timely basis
- Label all medication and solutions even in sterile field
- Maintain and communicate accurate pt meds info
- Comply with CDC or WHO hand hygiene guidelines
- Implement evidence based practices to prevent infections CLABI
- Conduct a pre-procedure verification process
- Mark procedure site
- Perform a Time Out
Page 12
Epidemiology of Error
What are the most common types of adverse events?
Inadequate information flow Human performance problems Poor organizational transfer of knowledge Insufficient staffing patterns Technical failures Inadequate policies and procedures Defective Systems
Page 12
To Err is Human
National Academy of Sciences’ Institute of Medicine (IOM) initiated Quality of Healthcare in America project in 1998
- to develop a strategy that would result in a threshold improvement in quality over 10 yrs
- published ‘To Err is Human’ in 1999
- attributed 44,000 to 98,000 deaths to medical error
- projected deaths exceeded MVAs, breast CA, and AIDS
- projected societal financial costs between $17 and $29 billion
Page 13
Define medical error
The failure of a planned action to be completed as intended
- or
The use of a wrong plan to achieve an aim
Page 13
Which areas of the hospital carry the highest risk of errors?
ICU
OR
ED
Page 13
IOM Report
Four fundamental factors contributing to error
- Decentralized nature of healthcare delivery ‘non-system’
- Failure of the licensing systems to focus on errors
- Impediment of the liability system to identify errors
- Failure of third party providers to provide financial incentives to improve safety
- Most errors are felt to be system errors rather than individual problems
Page 13
IOM Report
Comprehensive strategy to reduce preventable medical errors with goal of 50% reduction over 5 yrs.
What were the four main foci?
- Establishing a national focus
- Center for Patient Safety funded - Identifying and learning from errors
- nationwide mandatory reporting - Raising performance standards
- improvement in safety w/ oversight - Implementing safety systems in HO
Page 13 - informational
IOM report resulted in congressional hearings
$50 mil appropriated to fund Agency for Healthcare Research and Quality
Contracted with National Quality Forum to create ‘never events’
- easily preventable events of sufficient importance that they should never occur in a properly functioning healthcare environment
Page 13
Types of Errors
Diagnostic
Treatment
Preventive
Other
Page 13
Diagnostic Errors
Delay in diagnosis
Failure to employ indicated tests
Use of outmoded tests or therapy
Failure to Act on results of monitoring or testing
Page 14
Treatment Errors
Performance error - operation, procedure, or test Administering treatment Dose or Method of using a drug Avoidable delay - In treatment - Responding to abnormal test Inappropriate (not indicated) care
Page 14
Preventive Errors
Failure to provide prophylactic treatment
Inadequate monitoring
Inadequate follow-up treatment
Page 14
Other Errors
Failure of Communication
Equipment Failure
Other System Failure
Page 14
Ten Rules for Redisign
CCK DSWTC PCN Care is based on a continuous healing relationship Care customized according to pt needs Knowledge is shared and info flows freely Decision making is evidence based Safety is a system property Waste is continuously decreased Transparency is necessary Clinician cooperation is a priority Patient is the source of control Needs are anticipated
Page 15
Systems Thinking
Includes a definition of systems that all come together to provide care
- providers, patients, support staff, clinical and admin processes, technology, information
Compromised of multiple layers that affect safety
- nation, state, hospital, caregiving unit
Page 15
Human Factors
Human errors
- facilitated by similarities in appearance of different meds
or
- by non-compatibility of equipment
Page 16
Human Factors Engineering
The discipline that attempts to identify and address human factor errors
- has been used to improve safety in many industries (auto, aviation, nuclear power plants)
- significantly reduced risk of injury in the OR by redesign of anesthesia equipment
Page 16
Applications of Human Factors Engineering
Usability Testing
Workarounds
Forcing Functions
Standardization
Page 16
Application of Human Factors Engineering to Improving Safety
Define Usability Testing
Testing of new systems and equipment under real-world conditions as much as possible in order to identify unintended consequences of new technology
Page 16
Application of Human Factors Engineering to Improving Safety
Define Workarounds -
- the consistent bypassing of policies or safety procedures by frontline workers
- frequently arise because of flawed or poorly designed systems that actually increase the time necessary for workers to complete a task
Page 16
Application of Human Factors Engineering to Improving Safety
Define Forcing Functions -
- an aspect of design that prevents an unintended or undesirable action from being performed or allows its performance only if another specific action is performed first
- example - removing concentrated potassium from general hospital wards
Page 16
Application of Human Factors Engineering to Improving Safety
Standardization
Axiom of human factors engineering in that
- equipment and processes should be standardized whenever possible in order to increase reliability, improve information flow, and minimize cross-training needs
Page 17
What is the WHO Safe Surgery Checklist?
A list of 19 measures that should be performed before an invasive procedure to improve the safety of that procedure
Steps divided to
- before anesthesia
- before skin incision
- before pt leaves the OR
Page 17
WHO Safe Surgery Checklist
Before induction of Anesthesia
- Confirm patient Identity
- Site marking
- Check of Anesthesia Machine and medication
- Pulse Ox in place and functioning
- Allergies?
- Difficult airway or aspiration risk?
- Risk of significant blood loss?
Page 17
WHO Safe Surgery Checklist
Before Skin Incision
- Confirm all team members have introduced themselves by name and role
- Confirm pt name, procedure, and site of incision
- Antibiotic Prophylaxis
- Review anticipated critical events
- Review pt specific concerns related to anesthesia
- Confirm sterility of equipment/equipment concerns
- Is essential imaging available
Page 17
WHO Safe Surgery Checklist
Before patient leaves the Operating Room
Nurse confirms - name of procedure - instrument, sponge, and needle counts - specimen labeling Any equipment problems to be addressed? Concerns for recovery or management
Page 18
Resiliency Efforts
Given that unexpected events occur
- there should be attention to detecting and mitigating
Resiliency approaches tap into the dynamic aspects of risk management and how organizations anticipate and adapt to changing conditions and recover from system anomalies
Page 18
Communication in disclosure of adverse events
TTAPE
- Telling the pt and family what happened
- in terms they can understand - Taking responsibility
- Apologizing
- Explaining what will be done to prevent similar errors
Page 18
Culture of Safety
Beliefs, attitudes, and values about work risk and safety
Mainly the distinction between errors resulting from
- deliberate unsafe acts
and
- errors that are a result of system failures
Page 18
Culture of Safety
Background
- concept originated outside of healthcare in studies of high reliability organizations that consistently minimize adverse events despite carrying out intrinsically complex and hazardous work
- HROs maintain a commitment to safety at all levels
Page 19
Culture of Safety
4 Key Features?
- Acknowledgment of high-risk
- Blame-free environment
- Encouragement of collaboration across ranks
- Organizational commitment of resources to address safety concerns
Page 19
Measuring and Achieving a Culture of Safety
- generally measured by surveys
- Agency for Healthcare Research and Quality’s (AHRQ) Patient Safety Culture Survey
- Safety Attitudes Questionnaire
Page 19
Just Culture
Identify and address systems issues
- that lead to unsafe behaviors
- while maintaining individual accountability
- and establishing zero tolerance for reckless behavior
Page 19
Just Culture
Distinctions
- Human Error - slips
- At-risk Behavior - taking shortcuts
- Reckless Behavior - ignoring required safety steps
Not a no-blame approach
- but instead assigns blame predicated on the type of behavior associated with the error even if there was no patient harm
- ie not performing a time out
Page 20 Active Error (Active Failure)
- errors that occur at the point of contact between a human and some aspect of a larger system
- generally readily apparent (pushing an incorrect button)
- almost always involve someone at the front line
- termed errors at the ‘sharp end’ (figuratively referring to a scalpel)
Page 20
Adverse Drug Event
Definition -
Examples -
An adverse event or injury resulting from medical care involving medication use
Anaphylaxis, major hemorrhage from heparin, Aminoglicoside-induced renal failure, Agranulocytosis from chloramphenicol
Page 20 - Describe Preventable ADE - Potential ADE - Non-Preventable ADE - Ameliorable ADE -
- involve an element of error (either omission or commission)
- medication error that reached the pt but did not cause any harm
- unavoidable ADE (drug rx on pt without prior history)
- not completely preventable, but could have been mitigated
Page 20
Adverse Drug Reaction -
- adverse effect produced by the use of a medication in the recommended manner (ie side effects)
- they are non-preventable ADEs
Page 20
Adverse Event -
- any injury caused by medical care
- pneumothorax, anaphylaxis, wound infection, hospital acquired delirium
- simply indicates that an undesirable clinical outcome resulted from some aspect of diagnosis or therapy
Page 20
Authority Gradient -
- balance of decision-making power or the steepness of command hierarchy in a given situation
Page 22
Blunt End -
- refers to the many layers of the healthcare system not in direct contact with patients, but which influence the personnel and equipment at the sharp end
- consists of those who set policy, manage healthcare institutions, design medical devices
Page 22 Close Call (Near Miss) -
- event or situation that did not produced patient injury, but only because of chance
- Pt w/ PCN allergy that gets PCN and does not have a reaction
- Nurse notices physician wrote order in the wrong chart
Page 22 Latent Error (or Latent Condition) -
- less apparent failures of organization or design that contributed to the occurrence of errors or allowed them to cause harm to patients
- ‘accidents waiting to happen’
- referred to errors at the blunt end (Active failures are at the sharp end)
Page 22
Mistakes -
- reflect failures during attentional behaviors (behaviors that require thought, analysis, and planning)
- ‘Lapse in Concentration’
- typically involve insufficient knowledge, reflect inexperience, or lack of training
- wrong diagnostic test or suboptimal medication
- Typically requires more training, supervision, or occasionally disciplinary action
Page 23
Potential ADE -
- medication error or other drug-related mishap that reached the patient but happened not to produce harm (PCN allergy pt but no bad reaction)
Page 23
Sharp End -
- personnel or parts of the healthcare system in direct contact with pts
- literally holding the scalpel
- operating on the wrong leg
- error in programing an IV pump is at the sharp end
- institutions decision to use multiple types of infusion pumps (making programming errors more likely) is at the blunt end
Page 23
Sentinel Event -
- unexpected occurrence involving death or serious physical or psychological injury or the risk thereof
- serious injury specifically includes loss of limb or function
- ‘sentinel’ refers to the need for immediate investigation and response
Page 23
Failure Mode and Effects Analysis (FMEA)
- process used to prospectively identify error risk within a particular process
- begins with complete process mapping that identifies all steps that must take place for a given process to occur
- identifying the ways in which each step can go wrong (failure modes)
- identifying the probability that each error will be detected
- identifies the consequences or impact of the error not being detected
- these are all combined numerically to produce a Criticality Index
Page 23
Criticality Index -
- rough quantitative estimate of the magnitude of hazard posed by each step in a high-risk process
Page 24
Root Cause Analysis -
- a structured method used to analyze serious adverse events
- initially developed to analyze industrial accidents
- identifying underlying problems that increase the likelihood of errors while avoiding the trap of focusing on mistakes by individuals
- goal is to identify both active and latent errors
Page 24
RCA Process -
- begins with data collection and reconstruction of the event
- multidisciplinary team
- analyze the sequence of events leading to error
- identifying how the event occurred through ID of active errors
- identifying why the event occurred through the ID of latent errors
- goal of RCA is to prevent future harm by eliminating latent errors
Page 24
Factors that may lead to Latent Errors
- Institutional/ regulatory
- Organizational / Management
- Work Environment
- Team environment
- Staffing
- Task-related
- Patient Characteristics
Page 24
Factors that may lead to Latent Errors
Examples - Institutional / Regulatory
- a patient on anticoagulants received an intramuscular pneumococcal vaccination, resulting in a hematoma and prolonged hospitalization because the hospital was under regulatory pressure to improve its pneumococcal vaccination rates
Page 24
Factors that may lead to Latent Errors
Examples - Organizational / management
- a nurse detected a medication error, but the physician discouraged her from reporting it
Page 24
Factors that may lead to Latent Errors
Examples - Work Environment
- lacking the appropriate equipment to perform hysteroscopy, operating room staff improvised using equipment from other sets. During the operation, the patient suffered an air embolism
Page 24
Factors that may lead to Latent Errors
Examples - Team Environment
- a surgeon completed an operation despite being informed by a nurse and the anesthesiologist that the suction catheter tip was missing. The tip was subsequently found inside the patient, requiring re-operation
Page 24
Factors that may lead to Latent Errors
Examples - Staffing
- an overworked nurse mistakenly administered insulin instead of an anti-nausea medication, resulting in hypoglycemic coma
Page 24
Factors that may lead to Latent Errors
Examples - Task Related
- an intern incorrectly calculated the equivalent dose of long-acting MS Contin for a patient who had been receiving Vicodin. The patient experienced an opiate overdose and aspiration pneumonia, resulting in a prolonged ICU course
Page 24
Factors that may lead to Latent Errors
Examples - Patient Characteristics
- the parents of a young boy misread the instructions on a bottle of acetaminophen, causing their child to experience liver damage
Page 25
Medication Reconciliation -
- the process of avoiding inadvertent inconsistencies across transitions in care by reviewing the patient’s complete medication regimen at the time of admission, transfer, and discharge and comparing it with the regimen being considered for the new setting of care
Page 27
Name 6 patient Identifiers
- Name - Photo ID
- DOB - Phone #
- MR # - Last 4 SS #
Page 27
IR Procedures may require specific patient assessment
Who can perform the assessment?
What does it need to include?
- Radiologist, Nurse Practitioner, Physicians Assistant, or referring provider
- Focused History and Physical, assessment of risk factors for sedation if needed, and relevant labs
Page 27
Informed Consent
- required for invasive procedures
- may be required or at least advisable for some diagnostic imaging
- a process and not the simple act of signing a formal document
- should be obtained from the patient or the patient’s legal representative by the physician or other healthcare provider performing the procedure, or by other qualified personnel assisting that person
- the final responsibility for answering the patients questions and addressing any patient concerns rests with the physician
Page 27
Elements of Informed consent
- Discussion of the proposed procedure including benefits and potential risks (every conceivable risk does not need to be relayed to the patient), and reasonable alternatives to the procedure
- the patient should also be informed of the risks of refusing the procedure
- must be obtained before procedure-related sedation is administered
Page 28
How do you obtain consent when the patient is not able?
- from the patient’s appointed healthcare representative, legal guardian, or appropriate family member
- in emergency situations when the patient needs immediate care and consent cannot be obtained from the patient or a representative, the physician may provide treatment or perform a procedure ‘to prevent serious disability or death or to alleviate great pain or suffering
Page 28
Why do we perform a Time-out
- Joint Commission’s Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery
- Marking the incision site on the patient’s skin is required when there is more than one possible location for the procedure and when performing the procedure in a different location would negatively affect quality or safety
Page 28
What has to be confirmed during a time out?
- Patient Identity
- Correct site of the procedure
- Procedure being performed
Page 28
Maximum sterile barrier technique requires?
- Defined by the National Quality Measures Clearinghouse
- Cap, mask, sterile gown, sterile gloves, large sterile sheet, hand hygiene, and cutaneous antisepsis
Page 29
Minimal Sedation or Anxiolysis
- the administration of medications for the reduction of anxiety and the drug-induced state during which the patient responds to verbal commands
- in this state, cognitive function and coordination may be impaired, but ventilatory and cardiovascular functions are unaffected
Page 29
Moderate Sedation/Analgesia
- a minimally depressed level of consciousness 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
Page 29
Deep Sedation/ Analgesia
- drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation
- the ability to independently maintain ventilatory function may be impaired
- patients may require assistance in maintaining a patent airway and spontaneous ventilation may be inadequate
- cardiovascular function is usually maintained
Page 29
General Anesthesia
- a controlled state of unconsciousness in which there is a complete loss of protective reflexes, including the ability to maintain a patent airway independently and to respond appropriately to painful stimulation
Page 30
Anesthesiologists Physical Status Classification (ASA)
- Class I - normal healthy patient
- Class II - mild systemic disease
- Class III - severe systemic disease
- Class IV - severe systemic disease that is a constant threat to life
- Class V - moribund patient not expected to survive w/o operation
- Class VI - brain-dead, organs being removed for donor purposes
Page 30
Which ASA Classes qualify for moderate sedation?
- Class I and II
Page 30
Requirements for conscious sedation
- Nurse
- IV Access
- Continuous monitoring
- Level of Consciousness, RR, Pulse Ox, BP, HR, and Rhythm
- Similar monitoring is also needed in recovery
Page 30
Reversal Agents
- their duration of effect may be shorter than the sedating agent
- risk or relapse in to a deeper level of sedation
- level of consciousness and vital signs should return to acceptable levels for a period of two hours from the time of administration of the reversal agent before monitoring ends
Page 30
MR Safety
Four Zones
- Zone I - unrestricted
- Zone II - Interface between Zone’s I and IV
- Greet patients, obtain history, and screen pts for MR safety
- Zone III - there is potential danger of serious injury or death
- Scanner control room is in Zone III
- Strictly restricted with physical barriers including locks
- Zone IV - the MR scanner magnet room
- Highest risk area
- Should be clearly demarcated & marked as potentially hazardous
- Access should be under direct observation of MR personnel
- In a medical emergency, pt should be immediately removed to a
magnetically safe location while resuscitation is begun
Page 32
What is ‘Low Osmolality” contrast media relative to human serum?
Osmolality twice that of human serum
Page 32
What is the overall incidence of contrast media reactions?
0.2 to 0.7 %
Page 32
What is the incidence of severe or life threatening reactions?
0.01 - 0.02 %
Page 32
List three goals for contrast administration according to the ACR Manual on Contrast Media
- To assure that the administration of contrast is appropriate for the patient and the indication
- To minimize the likelihood of a contrast reaction
- To be fully prepared to treat a reaction should one occur
Page 32
What is the greatest risk factor for allergic contrast reaction?
- history of prior reaction to contrast
- associated with a five times increased risk of subsequent reaction
Page 32
What increases a patients risk of contrast reaction?
- Any other allergic history, particularly anaphylaxis
- Atopy (hyperallergic syndrome) results in a 2-3 times increased risk
- Asthma
- Significant Cardiac Disease
- Anxiety (controversial)
Page 32
What is the ideal route and timing of premedication?
- Oral medication at least six hours from initial administration of contrast
- Supplemental administration of H-1 antihistamine will reduce urticaria, angioedema, and respiratory symptoms
Page 32
How does the osmolality of contrast media affect the likelihood of a reaction?
- hyperosmolality stimulated release of histamine from basophils and mast cells
- increased size and complexity of the contrast molecule may also potentiate the release of histamine
Page 33
What are the two most frequently used elective premedication regimens listed in the ACR Manual on Contrast Media?
- Prednisone 50 mg po at 13, 7 and 1 hour before injection, plus Benadryl 50 mg IV / IM / or PO 1 hour before injection
- Methylprednisolone 32 mg by mouth 12 hours and 2 hours before injection, Benadryl may be added / 200 mg hydrocortisone IV may be substituted for oral prednisone if the patient is unable to take po
Page 33
Are IV Steroids effective for premedication?
-IV steroids have not been shown to be effective when administered fewer than 4-6 hours prior to contrast injection
Page 33
Name one regimen for IV contrast recommended by the ACR Manual for shorter time-frame premedication
- Solu-Medrol 40 mg or Solu-Cortef 200 mg IV every 4 hours until contrast study plus Benadryl 50 mg IV 1 hour prior to injection
Page 33
During a contrast reaction, what observations will allow the responding physician to quickly determine the severity of the reaction?
- Level of Consciousness - Lung Auscultation
- Appearance of the skin - Blood Pressure
- Quality of phonation - Heart Rate
Page 33
Contrast Reaction
Proper diagnosis of the reaction includes evaluating for?
- Urticaria - Vagal Reaction
- Facial or Laryngeal edema - Seizure
- Bronchospasm - Pulmonary Edema
- Hemodynamic Instability
Page 34
Classification of reactions
- Mild - signs and symptoms are self-limited without evidence of progression
- Moderate - signs and symptoms are more pronounced and commonly require medical management
- Severe - signs and symptoms are often life-threatening and can result in permanent morbidity or death if not managed appropriately
Page 34
Examples of severe allergic-like reactions
- diffuse or facial edema with dyspnea
- diffuse erythema with hypotension
- laryngeal edema with stridor / hypoxia
- wheezing or bronchospasm with significant hypoxia
- anaphylactic shock (hypotension and tachycardia)
Page 34
Examples of severe physiologic reactions
- vasovagal reaction unresponsive to treatment
- arrhythmia
- convulsions or seizures
- hypertensive emergency
Page 34
Management of contrast reactions
- Hives
- No treatment needed in most cases
- Benadryl if symptomatic - 25 to 50 mg PO for mild or IV if severe
- Allegra can be used as an alternative for Benadryl
- If severe
- epinephrine IM (1:1000) 0.3 ml (=0.3 mg) or
- epinephrine IV 1-3 ml or 1:10,000 dilution slowly into a running IV
- Monitor vital signs and maintain IV access in moderate/severe cases
Page 35
Management of contrast reactions
- Diffuse Erythema
- Preserve IV access, monitor vitals, pulse ox
- Mask O2, 6-10 liters/min
- If pt normotensive, no further treatment is usually needed
- If pt is hypotensive, give 1000 cc IV fluids rapidly
- Profound hypotension
- Consider epinephrine 1:10,000 IV 1-3 cc slow IV infusion
- can be repeated q 5-10 min as needed up to 10 cc (1mg) - If no IV, give epi IM (1:1000) 0.3 ml (=0.3 mg) up to 1 mg
- Consider epinephrine 1:10,000 IV 1-3 cc slow IV infusion
Page 35
Management of contrast reactions
- Laryngeal Edema
- Preserve IV access, monitor vitals, pulse ox
- O2 at 6 to 10 liters/min
- Epinephrine IM (1:1000) 0.3 ml (=0.3 mg)
- If hypotensive - Epinephrine IV (1:10,000) 1 to 3 ml (=0.1 to 0.3 mg) slow infusion
- Repeat epinephrine as needed up to a maximum of 1 mg
- Consider calling emergency response team
Page 35
Management of contrast reactions
- Bronchospasm
- Preserve IV, monitor vitals, pulse ox
- Mask O2 at 6 to 10 liters / min
- Beta-agonist inhaler albuterol 2 puffs (90 mcg per puff)
- In moderate cases consider epi / may repeat up to 1 mg
- IV epi in severe cases
- Consider calling emergency response team
Page 35
Management of contrast reactions
- Hypotension of any cause
- Systolic BP of less than 90
- Preserve IV access
- Elevate legs or Trendelenburg
- Mask O2
- Rapid IV fluids
Page 36
Management of contrast reactions
- Hypotension with Bradycardia (pulse of less than 60 bpm
- Vagal Reaction
- If mild, no additional treatment is needed beyond that listed for any cause (Trendelenburg, IV bolus)
- If severe, give ATROPINE 0.6 to 1.0 mg IV slowly, followed by NS flush
- May repeat atropine up to 3 mg
- Consider calling emergency response team
Page 36 Management of contrast reactions - Hypotension with Tachycardia - Pulse less than100 bpm - Anaphylactoid Reaction
- If persists after basic measures
- -> EPINEPHRINE
- Consider calling emergency response team
Page 36 Management of contrast reactions - Hypertensive Crisis - Diastolic above 120 - Systolic above 200 - sxs of end organ compromise
- Preserve IV access, monitor vitals, pulse ox
- O2 at 6 to 10 liters/min
- LABETALOL 20 mg IV slowly over 2 min, can double dose every 10 min
- If no labetalol, NITROGLYCERINE 0.4 mg sublingual, repeat q 5-10 min
- LASIX 20-40 mg IV slowly over 2 min
- Call emergency response team
Page 36
Management of contrast reactions
- Seizures or Convulsions
- Observe and protect patient
- Turn patient on side to avoid aspiration
- Suction airway as needed
- Preserve IV access, monitor vitals, pulse ox
- O2 at 6 to 10 liters / min
- LORAZEPAM 2-4 mg IV slowly to max dose of 4 mg
Page 36
Management of contrast reactions
- Pulmonary Edema
- Preserve IV access, monitor vitals, pulse ox
- O2 at 6 to 10 liters / min
- Elevate head of bed
- LASIX 20 to 40 mg IV slowly over 2 min
- Consider MORPHINE 1 to 3 mg IV, may repeat 5-10 min
- Consider calling emergency response team
Page 37
Management of contrast reactions
- Hypoglycemia
- Preserve IV access
- O2 at 6 to 10 liters/ min
- ORAL GLUCOSE if possible, 15 g of glucose tablet or 4 oz juice
- If unable to swallow, D50W 1 ampule (25 mg) IV over 2 min
- If unable to swallow and no IV, give GLUCAGON 1 mg IM
Page 37
Management of contrast reactions
- Unresponsive ad pulseless
- Check responsiveness
- Activate emergency response team or call 911
- Perform CPR
- Defibrillate if available
- EPINEPHRINE IV (1:10,000) 10 cc between 2 min cycles
Page 37
Management of contrast reactions
- Anxiety (panic attack)
- Diagnosis of exclusion
- Pt must be asessed for developing signs and symptoms of another more severe reaction or condition, such as those listed
- Preserve IV access, monitor vitals, pulse ox
- If there is no identifiable manifestations of another diagnosis and there is normal oxygenation, consider this diagnosis
- Reassure patient
