36C24218R0169-062.pdf

Revised April 11, 2018

RADIOLOGY DEPARTMENT POLICY AND PROCEDURES

MANUAL

VETERANS AFFAIRS OF WESTERN NEW YORK

Buffalo, New York 14215

RFP 36C24218R0169

D.36 RADIOLOGY SERVICE MANUAL

Table of Contents

SECTION I

I . Introduction /Mission………………………………………………

II . Personnel Responsibilities …………………………………………

III. Hours of Operation…. ………………………………………………

IV. Radiology Routine/Non routine Request/ Test Ordering Procedures

V. Privacy………………………………………………………………..

VI. CQI/ Peer Review/ Protocol Optimization………………………….

VII. Center Memorandum 114-01 Preparation for Radiologic Procedures

VIII. Center Memorandum 114-04 Administration of Oral and Parenteral

Contrast and Diagnostic Agents……………………………………..

IX. Contrast Media Policy VA of WNY……………………………………

SECTION II

X. Infection Control policies…………………………………………….

XI. Medication Policy…………………………………………………….

XII. Critical Result Communication………………………………………

XIII. Radiologic Techniques…………………………………………….…

SECTION III

XIV. Mammography…………………………………………………………..

XV. MRI………………………………………………………………………

XVI. CT………………………………………………………………………...

XVII. Ultrasound……………………………………………………………….

XVIII. Radiography……………………………………………………………..

XIX. Interventional Radiology…………………………………………………

XX. Safety…………………………………………………………………….

XXI. Radiology Inventory……………………………………………………..

RADIOLOGY SERVICE MANUAL INTRODUCTION

The radiology policy and procedures manual is a guide to the daily operation of the radiology department. It provides a concise reference for orientation of new personnel to the radiology department and a source of information to answer questions in the absence of the regular radiology staff.

Our mission is to provide our veterans and their families utmost exceptional care. The contents of this manual are in a constant state of change to promote and incorporate advancements in guidelines, equipment, technology, and patient and staff safety.

MEDICAL CENTER MISSION

To care for our Veterans with compassion and excellence.

“I CARE” core values

Integrity, Compassion, Advocacy, Respect and Excellence

II. Personnel Responsibilities:

A. All radiologists, imaging physicians, and medical physicists in a radiology service are supervised by a physician Section Chief. All Section Chiefs are supervised by the Chief of Radiology.

B. All technologists report to a higher grade technologist. The highest grade technologist, who is often called the Lead Technologist, is supervised by Manger of Radiology, who is then supervised by the Chief of Radiology.

C. The Chief of Radiology reports to a higher rank physician. Ordinarily this is the Chief of Staff.

D. Chief of Radiology:

Credentials

The Chief of Radiology is certified by the American Board of Radiology (ABR, as required by

VHA Handbook 1100.19, Credentialing and Privileging). For candidates not board-certified, or board certified in a specialty not appropriate for the assignment, the medical staff’s Executive

Committee affirmatively establishes and documents, through the privilege delineation process, that the person possesses comparable competence. If the Chief of Radiology is not board certified, the Credentialing and Privileging file must contain documentation that the individual has been determined to be equally qualified based on experience and the hospital's quality improvement data. Note: Chief Techs and non-imaging physicians may not act as Chief of

Imaging Service.

Role

The Chief of Radiology administers the activities of the service to include:

Planning for the provision of care, including adequate personnel, diagnostic equipment, and supplies to ensure availability of those procedures which are appropriate to the needs of the facility;

Providing a timely and quality product;

Equitable radiologist duty assignments which are appropriate to training and experience;

Development of, and adherence to, standard procedures and protocols;

Monitoring of activities which improve patient safety, performance, and quality;

Maintaining a safe radiation environment;

Ensuring patient privacy and confidentiality of patient medical information;

http://vaww.va.gov/VHApublications/ViewPublication.asp?pub_ID=2910

Ensuring accurate CPT coding and assignment of workload as well as DSS resource mapping and physician labor mapping parameters;

Ensuring compliance with federal statues, VA directives and polices, and The Joint

Commission standards.

Responsibilities

The Chief of Radiology is responsible for:

Recommending privileging requirements for the performance of radiologic procedures, based on training and/or experience, current competence and health status, as well as consideration of any information related to medical malpractice allegations or judgments, loss of medical staff membership, loss and/or reduction of clinical privileges, or challenges to licensure.

Reviewing all requests for initial and renewal credentials and clinical privileges and making recommendations regarding appointment and privileging action. The Chief of

Radiology must maintain performance data on all physicians and use this data in recommending renewal of privileges. Physician performance data includes competency review of interpretations, personal workload, maintenance of certification, and participation/attendance in quality improvement activities. In addition, it may contain other factors as deemed necessary by the service chief. These might include:

o Letters of complaint and praise;

o Honors and awards;

o Educational programs attended;

o BLS, ACLS certification as appropriate;

o Fluoroscopy permits and licenses per local, state, and/or Federal Regulations.

o Certificates of Additional Qualification;

o Medical Board licensure actions;

o Loss of privileges at other medical centers;

o Timeliness of service;

o Attendance and availability;

o Research and teaching activities;

o Evaluations from residents;

Establishing plans and policies which are consistent with federal regulations, VHA

Directives, and The Joint Commission standards. These plans and polices should include, but are not limited to, the following:

o Radiology Service Provision of Care Plan, including scope, hours of service, and staffing;

o Organization chart;

o Quality Improvement Plan;

o Ordering, approval, and scheduling of studies, listing those study orders requiring prior approval by a radiologist;

o Informed consent, including protocols for screening patients who require signature consent;

o Injection of intravenous contrast agents;

o Procedures for no-show patients, and patients who cannot be scheduled;

o Interpretation and reporting of procedures;

o Preliminary reports and communication of urgent results;

o Protocol and procedure manuals for each modality;

o MRI safety policy;

o Image storage and data integrity, image availability;

o Contingency plan when the information system is not operational;

o Resident supervision policy, delineating levels of supervision (if the hospital has a residency program);

o Radiation safety procedures, including safe use of fluoroscopy and the reporting and documentation of excessive patient exposures.

o Quality assurance procedures, addressing all aspects of the imaging process from image acquisition through image display.

o Physician Productivity. Monitoring the productivity of imaging physicians to ensure the average workload of the service meets VHA defined benchmarks, and developing corrective plans if it does not. See Productivity and Staffing Guidance for Imaging

Physicians Directive 2008-09.

Delegation of Responsibilities

Supervision of medical care responsibilities may be delegated to qualified physicians as appropriate. The Chief of Radiology remains responsible for the oversight of any delegated duties or authority.

E. Imaging Physicians http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1653

Role

Radiologists are physicians who have completed an Accreditation Council for Graduate

Medical Education (ACGME) accredited radiology residency program, or an equivalent foreign program, and who perform and interpret diagnostic imaging or interventional studies. Radiologists follow the guidelines of the American College of Radiology (ACR) and American Institute of Ultrasound in Medicine (AIUM) in regard to the Standard of

Practice, and they are guided by the Appropriateness Criteria developed by the ACR.

Radiologists act as consultants to clinical services.

As licensed independent practitioners, radiologists may change the ordering physician’s request to a more appropriate study in the correct clinical setting if it is emergent and the ordering provider could not be reached to change order. The radiologist may expand upon the ordered study or limit it, and may order imaging studies, taking care to consult the treating physician whenever possible. Radiologists will act in the patient’s interest in ensuring studies are indicated and safe.

If a new order is needed for an exam due to changes, the radiology staff will attempt to obtain a new order, but if after two unsuccessful attempts, the exam will be performed as ordered with limitations stated in the dictation.

Radiologists document their procedures, consultations and health care decisions in the medical record.

Radiologists communicate emergent findings directly to the treating service in a timely manner.

Radiologists supervise and direct the activities of residents, technologists and nurses working in the service.

Radiologists supervise the administration of medications, including contrast agents, by technologists and nurses.

Radiologists participate in quality assurance activities.

Qualifications

VA employee staff physicians who provide medical care at a VA facility must possess a full, active and unrestricted medical license from one of the states or territories of the

United States or the District of Columbia or the Commonwealth of Puerto Rico. All staff physicians must be credentialed and privileged for those procedures which they perform or supervise in accordance with VHA Handbook 1100.19, Credentialing and Privileging.

Each medical center determines whether Board Eligibility, Board Certification or http://vaww.va.gov/VHApublications/ViewPublication.asp?pub_ID=2910

Certificates of Added Qualifications are required for staff privileges. If the physician is foreign trained, the Chief of Radiology must determine that the training and subsequent experience are equivalent to ACGME residency training. The ABR provides guidelines for board eligibility of international medical graduates that may guide the Chief of

Radiology in making this determination.

Contract physicians are credentialed and privileged members of the medical staff who meet the same licensure and privileging standards as staff physicians.

Teleradiologists who communicate preliminary or final reports directly to the treating physician must be credentialed and privileged as outlined in VHA Directive 2007-034.

Teleradiologists meet the same licensure and privileging requirements as staff radiologists. The requirements of Title 38 USC 7402(f) (This link leaves the Department of Veterans Affairs Website) are applicable.

Teleradiologists who are privileged to practice teleradiology at a The Joint Commission accredited VA teleradiology service that has a The Joint Commission approved teleradiology QA program, need not be privileged at the hospital requesting service. This applies to the practice of teleradiology only. If the teleradiologist provides other types of radiology services, they must be separately privileged at each hospital for which they do so, and QA competency data of that physician must be made available to all sites at which he/she is privileged. For example, if a radiologist provides on-site radiology services at VA hospital A, and serves as a teleradiologist at VA teleradiology center B which interprets studies from VA hospital C, then that radiologist must be privileged at both A and B but not C, and competency data from A and B must be considered in appointment actions at either location. See VHA Directive 2007-034; Privileging for

VHA Teleradiology.

Note that a radiologist or teleradiologist need not be privileged to communicate preliminary interpretations or observations to a VA radiologist, who then uses that information in formulating an interpretation to the treating physician, so long as the radiologist who was consulted does not enter their observations in the medical record.

Residents must be supervised by an attending radiologist who is privileged to practice at the VA facility (see VHA Handbook 1400.01). The level and proximity of supervision must comply with the medical school policy for graduated supervision, and this level of supervision must be supported by objective educational or competency criteria. Residents may not provide final interpretations, but may provide preliminary interpretations for those studies that are appropriate to their level of training http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1606 http://uscode.house.gov/view.xhtml?req=(title:38%20section:7402%20edition:prelim)%20OR%20(granuleid:USC-prelim-title38-section7402)&f=treesort&edition=prelim&num=0&jumpTo=true http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1606 http://vaww1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1606 http://vaww.va.gov/VHApublications/ViewPublication.asp?pub_ID=2847

F. Diagnostic Radiologic Technologists

Roles and Responsibilities

DRTs are Hybrid Title-38 GS-647 occupation series employees who are trained in the operation of equipment employing radiant energy for the purpose of diagnosis and treatment of the human body. Modalities of equipment operated by DRTs include radiography, mammography, fluoroscopy, DXA, ultrasound, CT, and MRI.

Technologists act under the supervision of a radiologist.

Using protocols determined by the radiologist, the technologist is responsible for patient identification and safety screening, explanation of the procedure to the patient, proper shielding and positioning, selection of technical acquisition factors, and initial quality control of images.

Technologists may administer contrast agents or saline depending on protocoled exam, under the supervision of a physician. The physician can be either present or immediately available. Technologists may start peripheral intravenous lines for the purpose of contrast administration if they have undertaken training to do so, or have graduated from an American Registry of Radiologic Technologists (ARRT) recognized program that includes intravenous access in its curriculum, and have demonstrated competency by a period of proctoring.

Technologists do not interpret studies, but may communicate observations to the radiologist.

Technologists participate in the radiology service quality assurance program as required by their supervisor.

Technologists may change exam modifier (Left or Right) in the appropriate setting if he or she discovers that the current order for the patient has the incorrect laterality modifier and information was confirmed by patient and/or ordering provider (either direct communication such as phone, email, Lync, or through information in CPRS).

Technologists should follow department approved protocols for examinations during non-administrative hours when there is no in house radiologist to protocol an exam. Any questions regarding an exam during non-administrative hours if not readily answered through department policies should be referred to the on call radiologist.

Qualifications

Qualification standards can be found in VA Handbook 5005/15, Part II, Appendix G25.

http://vaww1.va.gov/ohrm/Directives-Handbooks/Documents/5005-15.pdf

Citizenship. Technologists are citizens of the United States.

Certification. Public Law 97-35 (This link leaves the Department of Veterans Affairs

Website), the Consumer-Patient Radiation Health and Safety Act of 1981, requires that persons who administer radiologic procedures meet the credentialing standards in 42

CFR Part 75 (This link leaves the Department of Veterans Affairs Website), Standards for the Accreditation of Educational Programs and the Credentialing of Radiographic

Personnel. They must have successfully completed an educational program that meets or exceeds the standards described in that regulation and is accredited by an organization recognized by the Department of Education, and be certified as radiographers in their field. The following personnel meet these requirements:

o Diagnostic Radiologic Technologists RT(R) certified by ARRT.

o Uncertified VA Diagnostic Radiologic Technicians/Technologists who were permanently employed on June 21, 1986, and whose competence in the safe administration of ionizing radiation was affirmed in writing by a VA licensed physician not later than January 1, 1987. These employees are considered fully qualified and may be promoted, demoted or reassigned within the GS-647 occupational series. Any employee initially retained in this manner who leaves this job series loses protected status and must meet the full requirements in effect at the time of reentry.

o Technologists must maintain their ARRT credentials in good standing by completing their mandatory 24 continuing education credits bi-annually.

English Language Proficiency. Diagnostic Radiologic Technologists are proficient in spoken and written English as required by 38 U.S.C. 7402(d) (This link leaves the

Department of Veterans Affairs Website), and 7407(d) (This link leaves the Department of Veterans Affairs Website).

Ultrasound certification. The proper performance of ultrasound examinations requires exceptional training and experience. It is strongly recommended that DRTs performing ultrasound be certified either by the American Registry of Diagnostic Medical

Sonographers (ARDMS) or by the ARRT (RT(S)).

Mammography Certification. The performance of mammography is a federally regulated imaging modality with specific certification requirements, which must be initially achieved and continually maintained. See the VHA Mammography Program Procedures and Standards, for these requirements.

http://history.nih.gov/research/downloads/PL97-35.pdf http://www.access.gpo.gov/nara/cfr/waisidx_02/42cfr75_02.html http://www.access.gpo.gov/nara/cfr/waisidx_02/42cfr75_02.html http://uscode.house.gov/view.xhtml?req=(title:38%20section:7402%20edition:prelim)%20OR%20(granuleid:USC-prelim-title38-section7402)&f=treesort&edition=prelim&num=0&jumpTo=true http://uscode.house.gov/view.xhtml?hl=false&edition=prelim&req=granuleid%3AUSC-prelim-title38-section7407&f=treesort&num=0&saved=%7CKHRpdGxlOjM4IHNlY3Rpb246NzQwMiBlZGl0aW9uOnByZWxpbSkgT1IgKGdyYW51bGVpZDpVU0MtcHJlbGltLXRpdGxlMzgtc2VjdGlvbjc0MDIp%7CdHJlZXNvcnQ%3D%7C%7C0%7Cfalse%7Cprelim http://vaww.va.gov/RADIOLOGY/Mammography/May2011Documents/MammographyProgramHandbook1105_03HK5_3_2011.pdf http://vaww.va.gov/RADIOLOGY/Mammography/May2011Documents/MammographyProgramHandbook1105_03HK5_3_2011.pdf

Operation of hybrid PET-CT equipment. DRTs who perform the Positron Emission

Tomography (PET) portion of a hybrid PET-CT exam, or nuclear medicine technologists who perform the CT portion of a hybrid PET-CT exam, must obtain additional education or training and demonstrate competency. Varying amounts of education will be required, depending upon the practitioner’s existing background, skills and knowledge. The

American Society of Radiologic Technologists (ASRT) and the Society of Nuclear

Medicine Technologist Section (SNMTS) have developed an educational gap analysis that identifies the component parts of the necessary educational program. Additional information concerning the PET-CT curriculum is available from the Society of Nuclear

Medicine or the ASRT.

Exceptions.

o Non-citizens may be appointed when it is not possible to recruit qualified citizens ( 38

U.S.C. 7407(a) [This link leaves the Department of Veterans Affairs Website] ).

o DRT applicants who have completed an approved training program, but who are not certified, may be given a temporary appointment. Employees who fail to acquire ARRT certification during the period of temporary employment may be terminated. The term of temporary employment is delineated in qualification standards documents available from the Human Resources Service.

o If there are no acceptable applicants who meet these requirements, the Chief Officer, Patient Care Services, may authorize a medical center to hire otherwise qualified applicants, provided such persons show evidence of training, experience, and competence to be equally protective of patient health and safety.

G. Medical Support Assistants

ROLES

The Advanced Medical Support Assistant is the key liaison with the clinical staff assigned to Imaging Service.

The incumbent must act on and carry out duties independently. The key concept in Imaging is a strong interdisciplinary team with total commitment to quality patient care. This position serves as a link between the patient, clinical/technical and administrative staff.

On a rotational basis, the Advanced Medical Support Assistant independently serves as the administrative coordinator for seven imaging clinics of the Radiology Department: (1) Computerized http://uscode.house.gov/view.xhtml?hl=false&edition=prelim&req=granuleid%3AUSC-prelim-title38-section7407&f=treesort&num=0&saved=%7CKHRpdGxlOjM4IHNlY3Rpb246NzQwMiBlZGl0aW9uOnByZWxpbSkgT1IgKGdyYW51bGVpZDpVU0MtcHJlbGltLXRpdGxlMzgtc2VjdGlvbjc0MDIp%7CdHJlZXNvcnQ%3D%7C%7C0%7Cfalse%7Cprelim http://uscode.house.gov/view.xhtml?hl=false&edition=prelim&req=granuleid%3AUSC-prelim-title38-section7407&f=treesort&num=0&saved=%7CKHRpdGxlOjM4IHNlY3Rpb246NzQwMiBlZGl0aW9uOnByZWxpbSkgT1IgKGdyYW51bGVpZDpVU0MtcHJlbGltLXRpdGxlMzgtc2VjdGlvbjc0MDIp%7CdHJlZXNvcnQ%3D%7C%7C0%7Cfalse%7Cprelim

III. HOURS OF OPERATION

The Radiology mission provides coverage 24 hours per day, 7 days per week, including holidays. This is accomplished by providing regular administrative hours from

8:00 am – 4:30 pm, Monday through Friday. On weekends and holidays, regular hours are 8:00 am – 4:30 pm, with reduced staff. There is full coverage during the 4:00 pm –

8:00 am shift utilizing an emergency staff of one or two technologists.

Tomography (CT) Clinic, (2) Magnetic Resonance Imaging (MRI) Clinic, (3) Ultrasound (US) Clinic,

(4) General Diagnostic Clinic, (5) Mammography Clinic, (6) Interventional Radiology and (7) Nuclear

Medicine . Incumbent has overall responsibility for all administrative components of patient scheduling, pre-procedure, pre-operative testing, pre-operative screening, pre-procedural consenting, post-operative instructions and follow-up appointments.

The Advanced MSA works with the team to reinforce the plan of care and self-help solutions and entering appropriate information into the electronic record to include tracking of phone contact, monitoring pre-appointment requirements to assure readiness for patient visit/ procedure to include patient instruction and patient exam preparation letters. The position operates in the hub of activity in each of the imaging clinics, patient contact includes both inpatient and outpatient customers. The advanced MSA works collaboratively in an interdisciplinary coordinated care delivery model to include support for Speech, Cardiac Catheterization Laboratory, Operating Room (Vascular, General and

Pulmonology), and primary care for outside facilities and within the VA of WNY. The incumbent responsibilities will include tracking and initiating non VA care for MRI requests with the facility and at a VISN level. Pending lists are reviewed and date is submitted to the VISN Imaging Council through

Chief of Radiology.

Patient Workload: Do to the high volume patients workload in each of the imaging clinics the incumbent will maintain a continuous workflow rate in an expeditious and effective manner in order to meet the daily patient schedule and/or daily patient workload in all seven imaging clinics. This requires the prioritization of inpatients and outpatients as well as the ability to accommodate the extreme emergency patient who may need immediate emergency surgery, etc. Errors made by the incumbent could delay or adversely affect patient care, and hinder the clinic operation causing unnecessary waiting for the patient, waste of professional work hours, and most importantly delay in patient’s imaging results and treatment.

The incumbent must have a working knowledge of VA policies, guidelines, HIPPA requirements, and eligibility benefits. Extensive knowledge of the Medical Center operations and personnel is required to refer customers to another specialized advisory as needed. The incumbent recognizes problems that could delay customers’ access to care and diagnostic examinations and initiates action to prevent such occurrences. The incumbent is expected to use common sense when the unexpected arises and knows when to seek guidance from the Chief of Radiology, Chief Radiology Administrator, Supervisory

Diagnostic Radiology Technologist (SDRT) and/or Lead Technologist when unusual circumstances present themselves.

The incumbent must provide efficient, professional service to our customers, displaying courtesy and professionalism, maintaining the customers’ dignity and privacy at all times which includes but is not limited to promoting the credibility, reputation, and image of MSA, the VASF-Medical Center, and the

Department of Veterans Affairs in dealings with patients, employees, and the general public.

OC: on call

MODALITY HOURS WEEKDAY HOURS

WEEKEND

COMMENT

MRI M-Thur 7am- 9pm /

FRI 7am-7:30pm

Sat 8am-4:30pm

Sun 8am -4:30pm

Schedules can vary based upon staffing levels

CT 24/7 24/7

US 7am -5:00pm then OC OC

General Radiology 24/7 24/7

Mammography 7am – 3pm None

Interventions 7am – 5pm None No on call IR

Batavia M,T,W,Th Varies Only general radiology

IV. ROUTINE REQUESTS/TEST ORDERING

Any examination which does not involve preparation for the patient should be referred to

Radiology as soon as possible. For example, the physician or ward/clinic clerk enters the radiology request via CPRS, the request will automatically print out in Radiology where it will be prioritized and scheduled in a logical sequence. Ward and clinics will then be notified via the computer of the date and time of the inpatient’s scheduled appointment.

A. Requests for Examination

No study will be done without an order requisition via CPRS which should be completed as follows:

a. The following information should be included:

Patient’s name

Patient’s birthdate

Patient’s FULL social security number

b. Location (ward or outpatient service, routing symbol, and telephone extension).

c. Examination requested.

d. Pertinent clinical history and physical findings which are consistent with the examination requested, and in accordance with ACR standards.

e. The requesting physician’s name, telephone extension and/or pager number.

f. Date of request

g. Date Desired:

i. ALL patients are scheduled as soon as possible, and placement of a clinically appropriate date will guide proper scheduling of patients.

ii. Radiology services will to the best of their ability schedule close to the clinically indicated desire date.

iii. Timelines of DESIRE DATES:

iv. STAT: Emergent exams for acutely or critically ill patients which can alter treatment plan of the patient in the immediately future.

Performed immediately on the same day.

v. URGENT: performed as soon as possible for matters requiring attention within 1-3 days.

vi. ROUTINE: nonemergent studies which encompasses majority of orders including but not limited to follow up examinations and chronic conditions.

vii. Follow up examination: Date desire should match timeframe of when followup should occur (i.e. 1 month, 3 months, 1 year).

viii. Other routine studies: exams should be performed within 30 days.

7) Mode of transportation (ambulatory, wheelchair, litter). The mode of transportation must be appropriate. Patients who must be lifted onto an examining table should not be sent in a wheelchair.

a. Interventional procedures: Must be transported on a litter.

b. Critically ill patients: Must be transported on a litter and a physician or nursing staff will need to accompany the patient. If the patient is on oxygen, that should be in place prior to the patient’s arrival to radiology.

c. Inpatients and Emergency Department patients: If the patient is critically ill and/or must be lifted onto the examining table, must be transported in a litter.

d. Transporting patients with suspected PE or Dissection:

1. Patient must be brought to radiology on a gurney.

2. Patient must be accompanied by nursing staff or physician.

3. Patient must not be left alone. Staff must stay with patient until procedure is complete.

4. Patient must have an IV or IV line in place.

5. Patient must be on oxygen (As clinically indicated ).

6. This practice must be followed by ER, WARDS AND

CLINICS .

e. Transporting stroke patients; please refer to facility stroke protocol.

8) Urgency of request

A. STAT: Study will be performed the day ordered. [Emergent studies requiring a Radiologist (e.g., fluoro, biopsy, CT or ultrasound) should be arranged with a radiologist]. In general, STAT portable plain film examinations are performed within thirty (30) minutes. STAT CT scans will be performed during the normal business hours or as a call case that day.

B. URGENT: Study will be performed within timeframe specified in history on x-ray request. If no timeframe is provided, patients will be scheduled in the next available inpatient or urgent appointment slot. In general, urgent plain film examinations are performed the same day as ordered. Urgent CT scans will generally be performed within two to three days or as specified by the ordering clinician.

C. ROUTINE: Study will be scheduled in the next available routine appointment slot. In general, routine inpatient plain film examinations ordered before 3:30 pm are performed the same day. Routine outpatient

CT scans will be performed on a next available basis. Our goal is to perform these studies as soon as possible and within 30 days.

9) Ward personnel should accompany patients who are very difficult to examine (e.g. paraplegics, disoriented, disturbed, or critically ill patients) to assist in handling, positioning, and watching such patients. Every effort will be made by the x-ray staff to expedite studies of these patients so the ward personnel will not be detained unnecessarily.

B. Scheduling

1) Sequence of Examinations

(a) All requisitions should be sent through CPRS where they will be sorted and scheduled. STAT/Urgent studies will, of course, take precedence. Those examinations that require immediate action should be marked ‘WET READING” and include a telephone extension or pager number if there is a critical finding according to critical finding policy. All wards and clinics will be notified of appointments via the computer.

(b) Request for examination requiring preparation, i.e.

Fluoroscopy, will be given an appointment time at least one day in advance. All procedures which require prep will receive an alert on the computer at the time the request is entered.

(d) Outpatient appointments requiring fluoroscopy or preparation will be made by the requesting clinic, radiology MSA, or radiology nurse via the computer.

(e) CT, MRI, and special procedure requests will need to be reviewed by a radiologist before performing. Interventional procedures will be scheduled in coordination with the radiology nurse.

(f) STAT or ED MRI add on during stated hours of operations will need to be reviewed by radiologist and MRI technologist before scheduling.

(g) Typically if the patient has multiple orders for x-rays (i.e. but not limited to, hands, wrists, feet, knees, etc), they can be performed on the same day.

2) Non Routine Requests

STAT and emergency studies should be requested only when so ordered by a physician. Requests shall be through CPRS and will be done as soon as the modality room and technologist are available. Emergency requests requiring fluoroscopy, MRI, or intervention should be discussed by the requesting physician with a radiologist.

3) Portable X-Rays

A portable x-ray examination is almost never as diagnostic as images taken in the x-ray department. For this reason a portable examination should NOT be requested unless the patient cannot come to the Radiology

Department. Further, only a limited number of technologists and portable machines are available, so that some delay may be experienced before portable examinations are completed.

PLEASE NOTE: The technologist may require the assistance of ward or outpatient personnel in completing portable examinations. Any person holding or assisting the technologist while an x-ray is done must wear a protective apron. Pregnant women and persons under 18 years of age should not be used to hold patients.

4) Telephone Requests

Telephone requests should be reserved for STAT, EMERGENCY, and portable examinations. When making a telephone request, the requestor must still enter the request through CPRS IMMEDIATELY.

ER exams are “STAT” and should always be done without delay.

5) RADIOLOGY NO-SHOW

Same day as appointment, an MSA who is assigned late shift will pull the orders from the black box and if the patient has not rescheduled that day and does not show up for appointment, the order is to be cancelled using reason #35 No Show, and a no show letter note will be sent to patient instructing them to contact provider for another order if necessary.

6) Scheduling Mandate: According to National Memorandum

8/12/2016

When making the 1 st attempt, place a note in CPRS with date of attempt and what was to be scheduled.

After first unsuccessful attempt, please send request letter to patient so he or she may contact us within 14 days to schedule. If after 14 days we do not hear back, please use cancel reason #98 (unable to contact patient to schedule)

The 1 st attempt to contact patient should be made within 7 days of order being placed

If we have to schedule a patient more than 30 days out because of radiology availability, be sure to place them on the veterans choice list.

If a patient request an appointment that is more than 30 days out in the info section where you put the type of study, also put date desired by patient if the appointment is more than 30 days out due to not being able to reach patient. They are not required to go on the veterans choice list.

Orders greater than 60 days are not valid and to be cancelled according to national radiology directive.

7) One Consult: From office of community care 11/30/2017

A team led by the Office of Community Care developed a standardized Radiology’s process for One Consult Model which became effective on November 22, 2017.

This requires all sites to change their naming convention from NON

VA CARE to COMMUNITY CARE-Specialty Name

Community Care Consult for all services (Services Unavailable) and able to forward VA in-house Consults (30 day Wait Time) with required Provisional Diagnosis (ICD-10 Code) listed.

https://vaww.vha.vaco.portal.va.gov/DUSHCC/DC/DO/CI/S/SitePage s/Presenters.aspx

Radiology’s SME’s came from sites that send out a few studies to a larger volume.

One Consult Model requires a radiology order and a consult per the contract.

For radiology studies ordered prior to the implementation date of

November 22, 2017, an ICD10 (provisional diagnosis code) is not required. Why? Because the One Consult Model did not get go into effect until November 22, 2017.

Effective November 22, 2017, any radiology study sent to the community will require an ICD10 code (provisional diagnosis).

Entry of an ICD10 (provisional diagnosis) codes must be entered by a clinical provider. The team’s consensus was that radiologists should not enter a consult. If a radiologist enters the consult then he/she would receive the result of the exam and be responsible for Veteran follow up care.

MSA’s cannot enter an ICD10 code since this is a clinical function.

Radiology services are to use the standardized consult naming conventions (see attached slide deck).

Dr. Barnett mentioned the Non-VA Imaging Center asked radiology to do this. Remember, non-VA providers do not set policy for VHA.

V. Privacy

All employees must comply by HIPPA regulations.

Failure to comply with this policy will result in disciplinary action.

VI. PROTOCOL/EQUIPMENT OPTIMIZATION AND CONTINUED

EDUCATION/PEER REVIEW

A. Protocol and equipment optimization:

a. Protocol and equipment testing and improvements should be performed if possible during non patient care hours to decrease the likelihood to compromise patient care.

b. Protocols revisions or additions will need to be reviewed by the chief of radiology before implementation.

c. The appropriate format for each protocol will need to be utilized as approved by the chief of radiology.

d. Using equipment to improve protocols and test functions on volunteers may be performed under the discretion of the chief of radiology once the risks and benefits have been reviewed to ensure the safety of the volunteer and staff.

e. The chief of radiology or supervisor must be made aware before the equipment in question is used for protocol/equipment optimization to assure patient care is not compromised. Results of the testing will be reviewed by a radiologist or supervisor.

https://vaww.vha.vaco.portal.va.gov/DUSHCC/DC/DO/CI/S/SitePages/Presenters.aspx https://vaww.vha.vaco.portal.va.gov/DUSHCC/DC/DO/CI/S/SitePages/Presenters.aspx

f. Under no circumstances is a radiology staff to utilize the radiology equipment for purposes other than for protocol improvement, equipment testing, continued education of staff, or servicing. For diagnostic purposes, an order must be submitted by the appropriate personnel in CPRS.

B. Continued education:

a. It is paramount for our staff to have continuous education on equipment, technique, and knowledge of their modality.

b. Radiology equipment may be utilized for these purposes, but if a volunteer is needed for practice, the modality MUST be non ionizing.

c. Peer Review for Radiologist:

i. As per JCAHO, each staff radiologist will participate in monthly peer review consisting of 10 studies each time.

ii. Studies will be reviewed on isite and comments will be documented on form provided.

iii. If discrepancy occurs, a third reviewer will be used, and the end result will be conveyed to the original radiologist for further actions if necessary.

iv. Results of peer review will be anonymized and uploaded to the radiology secure SharePoint and accessible only by that provider for educational purposes.

v. Scoring of peer review will be based upon ACR RADPEER:

d. Peer review for technologist:

Grading system

Grade Comments

1 - protocol followed

2 - Limitations secondary to unpreventable circumstances or technique i.e. body habitus, difficult patient, IV extravasation, etc

3 – Incorrect reformats/sequence or insufficient documentation.

i.e. not lining up with the joints, not including coronal MIPS, etc

4 – Limitations related to preventable errors in technique.

i.e. Not centering a patient, doing the wrong protocol or sequence, not including the area of concern, etc

5 – Technical callback Patient needs to be called back for correct/repeat imaging

VII. Center Memorandum 114-01 Preparation for Radiologic Procedures

CM114-01

PREPARATION FOR RADIOLOGIC PROCEDURES- final 2017.pdf

VIII. Center Memorandum 114-04 Administration of Oral and Parenteral

Contrast and Diagnostic Agents

CM114-04

ADMINISTRATION OF ORAL AND PARENTERAL CONTRAST AND DIAGNOSTIC AGENTS 2016 approved.pdf

IX. Contrast Media Policy VA of WNY

VA contrast media policy 2018.pdf

X. INFECTION CONTROL POLICIES – RADIOLOGY SERVICE

PERSONNEL PRACTICES:

1. Personnel wear established code of dress – uniforms, lab coat or jacket

2. Handwashing is performed and artificial fingernails prohibited in accordance with CM

11-71 “Guidelines for Hand Hygiene and Glove Usage”. Hands are decontaminated before and after patient contact, when entering on duty, at the completion of duty, after contact with contaminated equipment or medical devices, and after gloves are removed.

Alcohol foam antimicrobial hand rubs are available in patient rooms and are to be used for hand disinfection, as long as hands are not visibly contaminated. Hand washing sinks are also located in all patient care areas. A scrub sink is located in the Special

Procedures Room.

3. All radiology staff must complete TMS training V02 Infection Prevention and Control on an annual basis.

4. Food and Drink are allowed in designated areas only and strictly prohibited in patient care areas.

5. Employees with signs and symptoms of active infections are referred to the Employee

Health for determination of work status and limitation regarding patient contact.

6. Annual Influenza vaccines are offered free of charge to all employees and are mandatory as of November of 2017.

7. All Radiology department employees, determined to be at risk of potential risk for exposure to blood and body fluids, will be offered the Hepatitis B Vaccine.

8. Annual mandatory infection control education, inclusive of blood borne pathogens and

Tuberculosis, will be completed by radiology staff. All staff is aware of the location of the BBP exposure control plan – i.e. CM 11-47 “Exposure Control Plan for Blood borne

Pathogens” on SharePoint.

9. Sharps Safety Precautions: sharps with engineered sharps injury protection will be utilized when appropriate. In instances where a sharps safety technology is not available, work practice and other engineering control are utilized to reduce the possibility of sharps injury

PATIENT CARE PRACTICES:

1. Standard (Universal) precautions are followed for all patients. Personnel will wear personal protective wear – i.e., gloves, gowns, masks/eye protection to prevent exposure to blood and other body fluids, as appropriate for the procedure and type of exposure anticipated.

2. Personal protective equipment cabinets are available and are stocked by Radiology Staff as needed.

3. Sterile technique is used for all invasive procedures. All sterile materials should be checked prior to use and on a periodic basis for package integrity and expiration dates.

4. Skin preparation is performed using s 2% chlorhexidine gluconate or an iodophor antiseptic.

5. Sterile gloves, gowns, and masks are worn as appropriate by the provider performing the sterile procedure. The radiology technologist and radiology nurse serve as circulators.

6. Sterile drapes are used for invasive procedures.

7. Iodophor scrub brushes or 2% chlorhexidine gluconate antimicrobial skin cleanser is provided for surgical scrub prior to the procedure.

8. Traffic in and out of the Special Procedures room in kept to a minimum. Communication is limited to essential conversation to avoid contamination of the sterile field.

9. Syringes in sterile field must be labeled.

10. Linens are used on radiology tables and removed between patients. Mayo stands and tables, and any reusable equipment are cleaned between cases, after the proper disposal and removal of all contaminated supplies.

11. Patients on Isolation for known or suspected infection are identified by nursing personnel on the unit where the patient is housed BEFORE the patient is transported to Radiology Service, and proper communication to the radiology staff at the time of arrival to the radiology department.

12. Personnel follow written Medical Center guidelines for standard (universal) precautions and transmission based isolation practices (CM 11-41), as found in the Infection Control

Manual (SharePoint).

13. Radiology Service will be notified when a patient on “Airborne Precautions” is to have a radiological exam while they are in Isolation. A portable exam in the patient’s negative pressure room will be performed whenever possible and staff will wear a NIOSH approved respirator when entering the isolation room. The patient will be masked with a surgical mask, if it is necessary that the patient have his radiological exam performed in the Radiology department. The patient will be taken directly to the exam room and never placed in a waiting room.

EQUIPMENT/MATERIALS:

1. Disposable patient care items are used whenever possible (eg.barium enema bags, syringes).

2. Special procedure trays are disposable, non-disposable supplies are cleaned, processed and sterilized in SPS service.

3. Puncture-resistant sharps containers are used for disposal of all needles, syringes and other sharps in accordance with Center Memorandum 11-23 and changed by EMS when

¾ full.

4. Control boards, panels and sensitive equipment are cleaned on a routine basis using an

EPA-approved disinfectant/detergent.

5. Fan outlet parts on x-ray equipment are vacuumed during routine preventative maintenance procedures.

6. Clean linen is stored on covered carts. Soiled linen is placed into fluid-resistant laundry bags and removed off hampers when two-thirds full and replaced with clean bags.

7. Supplies for invasive procedures are stored in closed cabinets. Staff checks the integrity of all supplies and expiration dates prior to use.

ENVIRONMENTAL SANITATION:

1. Daily mopping is done by Environmental Management Service using tow-bucket technique. Additional mopping is done when obvious contamination occurs.

2. General trash is collected in plastic-lined containers daily by Environmental Management

Service.

3. Items identified as regulated medical waste are disposed of in accordance with Center

Memorandum No. 00-10 “Disposal of Regulated (Infectious) Medical Waste”.

4. Light tracks and walls in the Special Procedures room are to be cleaned quarterly and more often as needed by Environmental Management Service. Patient contact horizontal surface areas are cleaned by Radiology personnel on a daily basis and more often, as needed.

5. Tables are wiped with an EPA/hospital approved disinfectant/detergent solution by

Radiology staff after any procedure in which body secretions, excretions or fluids are handled.

6. Any disposable equipment or material used during an interventional procedure or diagnostic procedure that has been in contact with bodily fluids or blood is disposed in regulated medical waste containers.

STERILIZATION/DECONTAMINATION:

1. All non-disposable items – trays, sterile linens, gowns, etc. – are processed by the SPD department.

2. Needle guidance brackets (Civco) are soaked no longer soaked in cidex prior to transport to SPD department. They are to be placed in a metal container provided by SPD, which is then placed in a red lid covered bin. This is to be transported to SPD after usage for immediate sterilization.

Equipment: LOGIQ 9 Ultrasound Probes Model #(s): M12L, 4C, 9C, MLG-15, C1-5, 9-L Manufacturer: GE

DO NOT USE ALCOHOL BASED CLEANERS

Section 1: General Maintenance: By Department Owning Equipment

Step 4. Do not immerse probe in any liquid beyond the level indicated by the immersion level diagram on page 17-20.

Step 2. Do not drop the probes or subject them to other types of mechanical impact.

Step 3. Prior to each use, visually inspect the probe lens and case area for cracks, cuts, tears and other signs of physical damage. DO NOT use a probe which appears to be damaged until you verify functional and safe performance. Perform a thorough inspection, including the cable, strain relief and connector each time you clean the probe.

Step 4. Before inserting the connector in to the probe port, inspect the probe connector pins. If a pin is bent, do not use the probe until it has been inspected and repaired/replaced by a GE service representative.

Step 5. Do not use any alcohol based cleaner. This will cause irreparable damage to probe.

Step 6. DO NOT kink, tightly coil or apply excessive force on the probe cable. Insulation failure may result.

Section 2: User Cleaning (Cleaning done in Radiology)

Step 1. Don gloves.

Step 2. Disconnect the probe from the ultrasound console and remove all coupling gel from the probe by wiping with a soft lint free cloth.

Step 4. check probe for visible residue and rinse if needed

Step 5. Air dry or dry with a soft cloth.

Step 6. Using approved Caviwipes, wipe probe beginning lens end wiping toward strain relief and cable.

Step 7. Return probe to cradle on ultrasound console.

VAWNYHS STANDARD Operating Procedure: Reusable Medical Equipment (Semi-Critical)

Equipment: Ultra-Pro II Needle Guidance System Bracket Model #E8385NA GE-4C, H4906BK 9L Manufacturer: CIVCO

Section 1: General Maintenance: By Department Owning Equipment

Step 1. Do not drop the brackets or subject them to other types of mechanical impact.

Step 2. Prior to each use, visually inspect the brackets for cracks, cuts, tears, and other signs of physical damage. DO NOT use a bracket which appears to be damaged until you verify functional and safe performance. Perform a thorough inspection, each time you clean the bracket.

Section 2: User Cleaning (Cleaning done in Radiology)

Step 1. Don gloves.

Step 2. After each use, remove bracket and needle guide from transducer, discarding single-use, disposable components. Remove visible contaminants from bracket surface with flowing water. Wipe bracket using soft cloth moistened with T-Spray disinfectant or approved Caviwipes.

Step 3. Place probe in biohazard bin for transport to SPD for reprocessing.

XI. MEDICATION POLICY

A. Anxiolysis:

a. Single dose of prescribed medication in the Radiology Department for patients who are claustrophobic.

b. Levels of Anxiolysis will be minimal; patient will be able to respond to verbal commands.

c. Patient must have order already in CPRS entered by his/her provider.

d. Patient is to report to radiology 1 hour prior to exam time.

e. Patient must have a responsible adult to accompany the patient as driver. VA approved shuttles are not approved modes of transportation after administration of anxiolysis. Family member, trusted friend, DAV, or special travel by means of consult are approved forms of transportation.

f. MRI safety screening will occur prior to administration of medicine.

g. Time out before administration of medicine.

h. Nurse or radiologist will take vital signs before and after the examination (pre and post medicine administration).

i. The patient is monitored throughout the procedure, and if any adverse reactions, a physician will be notified immediately.

j. If anxiolysis are given by the house staff before radiology examination or procedure and consent is required, the…