What Do You Think?

Response to questions from the February 2002 issue: JCAHO Inspection I am the director of a low-risk diagnostic lab in northern Kentucky. We are preparing for our first JCAHO inspection, and would certainly appreciate any ideas on what to expect (hot spots, etc.) Sincerely, Sandy Shuler, RCIS Sandyshuler@aol.com Brian B, ARRT, CRT, RT(R): I work in a cath lab and interventional angio lab as well, in California. I have been through two JCAHO inspections. There are endless things that you need to prepare for and the ones you spend the most time on are the ones they won’t check (something about Murphy’s Law). Anyway, here are some things that you might want to look at: Fluoro checks. Have the x-ray physicist log sheets up to date. Patient confidentiality: charts, labs, computer screens, and that sort of thing Vendor consents, as in, is it okay with the patient to have a vendor watching them get their groin prepped. Staff competencies. Are they filled out and up to date? What kind of QA or QC program do you use? What are you doing about performance improvement? Make sure the staff knows the mission and values of the hospital. Have your best staff members there on the inspection days, you know who those people are. Don’t try and snow job the inspectors. Be honest and sincere. If they see you have your paperwork in order and are there to help them, it will go easier. Make sure everyone knows what your codes are, as in code blue, red, pink, strong…whatever they are. Know all about the fire codes and what to do with the patients. Where are the fire extinguishers and alarms? These are just a few simple things that I have seen inspectors ask for that were overlooked by our well-prepared staff. Good luck and remember, those who prepare, prepare to succeed. Response to questions from the March 2002 issue: Radiology Techs in Maryland Cath Lab Can anyone provide information about the requirements for there being a radiology tech in the cath lab in Maryland? I manage a cath lab in Maryland. I have only one rad tech and am having trouble hiring them because of the shortage. My supervisor in the radiology department says it is a state requirement to have a rad tech present during all cath procedures even if the physician is doing all the exposures and panning the table. Must you have a tech in the room or just available in the department? Can you have one tech available for 2 simultaneous procedures in adjoining rooms? Thank you, Robert G. Stryker, RN Email: rstryker@olg.com Dear Robert, It was interesting to read your question in the March issue of Cath Lab Digest concerning the requirements for having radiologic techs in the cath lab. As a RT with more than 15 years of experience in cath labs, I have come across this question before. This subject has recently been discussed in my facility. My facility is in California, so I really don’t know the requirements in Maryland. However, I can tell you as it relates to California laws and local policies. Regardless of whether or not there is a shortage of RTs, California state law requires a CRT (California’s equivalent to the federal RT) to be present during all cath procedures. California Title 17, section 30450, states: A radiologic technologist fluoroscopy permit issued by the Department shall be required of any technologist who exposes a patient to X-rays in a fluoroscopy mode, or who does one or more of the following during fluoroscopy of a patient: (a) Positions the patient. (b) Positions the fluoroscopy equipment. (c) Selects exposure factors. Only CRTs and physicians who have completed a special fluoroscopy course can be issued a permit in California. Nobody else. No RNs, CVTs, nor anybody else, even ˜under the direction of a physician’. Even RTs or CRTs without a Fluoroscopy Permit are excluded from being authorized to operate fluoroscopy equipment. There always seems to be some discussion about the three areas above. As these three areas relate to our particular cath lab equipment setup, the above is interpreted as follows: exposes a patient to X-rays in a fluoroscopy mode means: 1. Stepping on the fluoro pedal. 2. Stepping on the cine pedal. Positions the patient means: 1. Panning the patient during cine or fluoro. Positions the fluoroscopy equipment means: 1. Rotating the C-arm while the beam is on. Selects exposure factors covers a lot of ground and subject to perhaps the most varied interpretations. This is also the area where the CRT’s expertise is most needed: -Turning on and booting up the X-ray equipment involves selecting various options that directly controls the exposure to the patient. -Raising or lowering the image intensifier controls the exposure to the patient. -Raising or lowering the table directly controls the exposure to the patient. -Changing the magnification modes controls the exposure to the patient. -Collimating the beam directly controls the exposure to the patient. -There are other exposure factors that affect image quality and therefore indirectly affect exposure to the patient. If image quality is poor, the physician uses more fluoro or cine quantity to compensate for lack of fluoro or cine quality. I realize that some equipment is pretty much automatic and can be defaulted or set up to produce x-rays that can get the job done. After all, you can leave the collimators wide open, use the maximum dose on everybody, never change the magnification factor, never change the focal spot, never lower the image intensifier, etc. However, this would be very poor practice. Improperly trained personnel often do not select the proper exposure factors when they should and select the improper exposure factors when they should not. If the fluoroscopy-permitted physician was the ONLY one performing ALL the above duties, this would be acceptable in California. However, this is not the reality in our cath labs, and is not the reality in most cath labs in California. I’d bet that the physician is not the person doing all the above duties in your labs either. Therefore, a CRT is required to operate the X-ray equipment. There are other considerations concerning who is authorized to operate X-ray equipment: 1. Operating X-ray equipment by anybody except a fluoroscopy-permitted physician or CRT would be a violation of Title 22, sections 70253 and 70255. 2. This is also a violation of the principles of ALARA, As Low As Reasonably Achievable, partially described in Code of Federal Regulations, Subpart B, Section 20.1101. Operating X-ray equipment without a CRT is a highly questionable practice in today’s radiation-conscious environment. Without a CRT operating the X-ray equipment, unqualified, untrained, un-permitted, non-radiologic personnel are exposing patients and staff to unnecessary radiation that can be reduced by the expertise and professional judgement of a CRT. Having non-CRTs operating X-ray equipment in such a high radiation area as the cath lab shows a decreased commitment to patient safety, staff safety, and to the principles of ALARA. 3. This may also be a violation of your hospital’s current level of credentialing with JCAHO. Without a CRT operating the X-ray equipment, your lab may not meet the highest standard of JCAHO accreditation as per DR1.5, Section 4, of The Accreditation Manual for Hospitals. 4. Operating X-ray equipment by anybody except a fluoroscopy-permitted physician or CRT) would not meet the standard of care provided by other cath labs in our community. It’s the standard of care throughout San Diego for CRTs to operate cath lab x-ray equipment. Every other cath lab in San Diego has a CRT present, operating the X-ray equipment, during every cardiac cath. They do not allow CVTs, RNs or other non-CRT personnel to operate X-ray equipment. 5. This may also be a violation of Medicare billing ethics. I understand that in order to bill for Medicare reimbursement, procedures must be performed by qualified personnel. Only fluoroscopy-permitted CRTs and physicians are qualified to operate X-ray equipment. Requiring that a CRT is present during all cath procedures would resolve all the above issues. It is the only way to ensure that each patient and all room personnel are exposed to the minimum amount of radiation possible while still providing the highest quality images. I hope it has been of some help to you and others who run across this issue. Sincerely, Ken Benzel, RT (R), CRT, RCIS, kenbenz@sciti.com