With more pain procedures came higher dosimetry readings. We were already employing the basic standards for radiation protection including lead vests with thyroid shields, lead glasses, collimation and orientation of the X-ray tube below the pain table and yet our physicians had reached 75 percent of the quarterly radiation dose limit.
To further reduce exposure from scatter radiation, we looked to the three cardinal principles of radiation protection.
Minimize time. We began using the pulsed fluoroscopy setting for all live portions of procedures except where contraindicated by the physician (mainly in the cervical spine or any time maximum resolution is desirable).
Another concern: During pulsed fluoroscopy, a delay in X-ray termination time of greater than 1 second has caused our physicians' hands to enter the field of radiation, resulting in unnecessary exposure. To keep physicians' hands from entering the field of radiation during quick maneuvers such as placing needles for facet joint injections, we manually pulse standard fluoroscopy of 24 pps by keeping exposure time to less than 1 second.
For example, during a caudal catheter procedure you may use pulsed fluoroscopy until the physician begins to place needles for select nerve root injection (if needed). At this time, deactivate pulsed fluoroscopy and manually pulse the standard fluoroscopy setting by keeping exposure time less or equal to 1 second until the physician satisfactorily places the needle. Then you can reactivate pulsed fluoroscopy before contrast injection. After contrast injection, deactivate the pulsed setting for placement of the next needle.
Maximize shielding. We supplemented the lead protection, already being worn, by installing a table/patient lead shielding system. This consists of lead curtains that hang from three edges of the pain procedure table to the floor. Each curtain is 4 inches wide and hangs edge on edge to enclose the X-ray tube below the table on the sides of the physician, anesthesia staff and technologist. The width of each curtain allows the technician the freedom to swing the C-arm into a lateral position. Also included are a set of four lead blankets. The idea is to shield the patient superior and inferior to the sterile field and also lateral to the patient's sides. However, because the lateral shielding hinders lateral views of the spine, we don't use them in these cases.
Maximize distance. Although at times we could increase the distance that the physician stands from the patient, this technique is usually reserved for extreme cases of overexposure and doesn't apply to our physicians or facility.
The results* speak for themselves. Vigilant use of these techniques has greatly improved our ALARA (As Low As Reasonably Achievable) program for pain management. In six months, we've decreased our fluoro time by 50 percent, which has resulted in an equivalent decrease in dosimetry levels for our physicians.
Thomas Stafford, RT
Madison Surgery Center
A Little Green Dot for Staff Safety
We mark with a little green dot the charts of those patients who have such communicable diseases as hepatitis or AIDS. This alerts all caregivers who come in contact with the patient to take extra precautions, but doesn't violate HIPAA, which has really clamped down on how you share information. This is just a simple way for us to bring everybody's attention to the need for caution.
Donna Label, RN, MSN, CNOR
Sierra Nevada Hospital
Grass Valley, Calif.
Schedule Four Weeks In a Month
Maintaining an efficient block scheduling process accommodating surgeons' requested times and filling in holes when they're on vacation or otherwise absent is a trying enough task without having to deal with the irregularities of broken-up weeks at the beginnings or ends of months. How do you schedule the extra time or shortchanged surgeon if there are more Mondays in a given month than Wednesdays? At our facility we don't block schedule by calendar months, but rather by four-week cycles, 13 of them in a year. That way there's always the same number of weekdays for the surgeons who routinely book our ORs. We've coordinated this format with the schedulers at each physician's practice office, and we've found it helps to make us more efficient when we're freed from variable calendar pages.
Vanessa Tobias, RN
Pennsylvania Eye & Ear Surgery Center
How to Handle Specimen Handling Errors
What should you do if you accidentally put a piece of tissue intended for specimen bottle A in specimen bottle B? Follow these steps if you suspect that specimens got mixed up in the procedure room:
- On the surgical pathology requisition, write a brief summary of the possible error: "Two small tissue fragments designated by Dr. Jones as ???Barrett's at 36 cm' may have inadvertently been placed in specimen bottle B, designated ???antrum.' Dr. Jones has taken a total of six fragments from Barrett's and four fragments from the antrum."
- On the bottle label, write a large asterisk and "see note" to alert the pathology receiving staff, who may then alert the pathologist who may never see the requisition if it's not highlighted.
- On your specimen log, note "Possible specimen handling error."
- Be available to the pathologist and the laboratory staff to answer any questions about the possible error.
Do these four things even if the procedure physician tells you that the pathologist will be able to tell the difference in pathology when the tissue is under the microscope. Complete disclosure to the procedure physician and to the consulting physician (the pathologist) is essential to the proper handling of the specimen and maintaining the best diagnosis and care for the patient. Be sure to follow through to reconcile the diagnosis on the pathology report for the specimens submitted (for tissue type and diagnostic class) to determine if a specimen handling error occurred and whether the patient was impacted.
Julia Dahl, MD
Mosaic GI-Hepatic Pathology Services