Interventional Radiology Guideline - | Health



Canberra Hospital and Health ServicesClinical ProcedureInterventional Radiology (Angiography)Contents TOC \o "3-3" \h \z \t "Heading 1,1,Heading 2,2" Contents PAGEREF _Toc450821638 \h 1Purpose PAGEREF _Toc450821639 \h 3Alerts PAGEREF _Toc450821640 \h 3Scope PAGEREF _Toc450821641 \h 3Section 1 – Booking Process PAGEREF _Toc450821642 \h 31.1.Referral Source PAGEREF _Toc450821643 \h 31.2.In-patients, Emergency and Other Hospital Patients PAGEREF _Toc450821644 \h 31.3.Out-patients PAGEREF _Toc450821645 \h 4Section 2 – Pre-Procedure for outpatients only PAGEREF _Toc450821646 \h 52.1.Pre Admission Clinic PAGEREF _Toc450821647 \h 5Section 3 – Day of Procedure PAGEREF _Toc450821648 \h 53.1.Inpatients PAGEREF _Toc450821649 \h 53.1.1.Ward based Inpatients: PAGEREF _Toc450821650 \h 53.1.2.Day of Surgery Admission (DOSA) PAGEREF _Toc450821651 \h 63.2.Out Patients PAGEREF _Toc450821652 \h 63.2.1.Day Cases PAGEREF _Toc450821653 \h 63.3.In Medical Imaging Day ward or Interventional Radiology Suite PAGEREF _Toc450821654 \h 6Section 4 – In the Interventional Radiology Suite PAGEREF _Toc450821655 \h 7Section 5 – Procedures PAGEREF _Toc450821656 \h 85.1.Procedures Performed in the Interventional Suite PAGEREF _Toc450821657 \h 85.2.Equipment PAGEREF _Toc450821658 \h 95.3.Angiography Radiographer PAGEREF _Toc450821659 \h 9Section 6 – Post Procedure PAGEREF _Toc450821660 \h 9Section 7 – Discharge PAGEREF _Toc450821661 \h 107.1.Inpatients: PAGEREF _Toc450821662 \h 117.2.Out-patient: PAGEREF _Toc450821663 \h 117.2.1.Day care: PAGEREF _Toc450821664 \h 117.2.2.Day of Surgery Admission (DOSA): PAGEREF _Toc450821665 \h 11Implementation PAGEREF _Toc450821666 \h 11Related Policies, Procedures, Guidelines and Legislation PAGEREF _Toc450821667 \h 11Policies PAGEREF _Toc450821668 \h 11Guidelines PAGEREF _Toc450821669 \h 12Legislation PAGEREF _Toc450821670 \h 12Definition of Terms PAGEREF _Toc450821671 \h 12Search Terms PAGEREF _Toc450821672 \h 12Attachments PAGEREF _Toc450821673 \h 12Attachment A: Medical Imaging Angiography Record #65604 PAGEREF _Toc450821674 \h 14Attachment B: Paper Referral F00085(0902)51163 PAGEREF _Toc450821675 \h 18Attachment C: Medical Imaging Pre Interventional Checklist PAGEREF _Toc450821676 \h 20Attachment D: Radiology Preparation Orders and Check List #60370 PAGEREF _Toc450821677 \h 21PurposeThe purpose of this procedure is to describe the processes and steps required to manage patient care and ensure patient safety while undergoing Interventional Radiology procedures in the Canberra Hospital Medical Imaging Angiography Suite. ScopeAlertsStrict adherence to Lead Shielding Personal Protective Equipment (PPE) should be maintained, in accordance with the CHHS Radiation Management policy.Ensure adherence to the CHHS Patient Identification and Procedure Matching Procedure and the CHHS Clinical Handover policy at all times.ScopeThis procedure applies to the following:Interventional Radiologist, Fellow & RegistrarInterventional Nursing Staff trained in angiography proceduresInterventional Radiographers trained in angiography proceduresInterventional students under supervision in training for angiography procedures.Section 1 – Booking ProcessReferral SourceReferrals may be accepted from:Specialist/ Consultant Physician/ RegistrarGeneral PractitionersAll requests are reviewed by Interventional Radiologist for clinical history to assist in the planning of procedure. Metformin and warfarin are to be discussed with and ceased at the request of the Interventional Radiologist if required Radiologist or treating team will inform the patient.In-patients, Emergency and Other Hospital PatientsOnce a referral is received by Interventional Radiology, and prior to scheduling an appointment, a clinical discussion with the referring treating team and an Interventional Radiologist, registrar or fellow should occur to ensure: the appropriateness of the procedure/exam, and to establish the nature, purpose and urgency of the proposed procedure. Once the decision is made to go ahead with the procedure the Interventional Registrar/Radiologist and/or CNC triages the request and will action as follows:Urgent Procedures- Referring clinician must discuss with radiology registrar/radiologist who will liaise with radiography/nursing/administrative staff to arrange the procedure to be performed.After hours- The referring clinician will contact the Interventional Radiologist on Call via the Canberra Hospital switchboard.Routine Procedures- The CNC will liaise with administrative staff to schedule the procedure.Radiography/nursing/administrative staff will contact the ward and inform the nursing staff of the patient’s appointment.The referring clinician will then enter the referral electronically into Radiology Information System (RIS) or submits a paper referral (see Attachment B) to the Angiography Bookings Office accompanied by a completed Medical Imaging Pre Interventional Checklist (Attachment C). Paper referrals are entered and scanned into the Radiology Information System (RIS) by the Interventional Radiology administrative staff on receipt in the department. Radiology Preparation Orders and Check List (Attachment D) are to be partially completed by the Angiography ward clerk with relevant information in preparation for the patient’s booking. The form will then be taken to the ward with the remainder of the form being completed by the ward nurse prior to the patient being transferred to the Angiography Suite. Out-patients The Outpatient referral should be preceded by a clinical discussion between the Interventional Radiologist and referring clinician, Out-patients receive a proforma letter and pathology request by mail, which is generated from the CNC booking clerk. This includes those patients who are a Day of Surgery Admission (DOSA). The referring clinician enters the referral electronically on RIS or submits a paper referral to the Angiography Bookings Office accompanied by a Pre Interventional Checklist. Paper referrals are entered and scanned into the RIS on receipt at the Interventional Radiology Department.Ensure the following;Identify Clinical Indicators for the serviceclearly identify the referring doctor’s namedocument relevant information such as co-morbidities- as per the Medical Imaging Angiography Record attachedInterventional Registrar/ Radiologist +/- CNC triages on receipt of the request while indicating the following:If the procedure is deemed inappropriate on the basis of clinical information provided, the registrar or radiologist will contact the referring doctor to discuss an alternative or cancellation. The referring doctor is then expected to contact the patient to advise of the change/ cancellation. In the event of a patient not attending their appointment the patient will be phoned and the appointment rescheduled. If the patient does not attend for the second appointment a letter is sent to the referring doctor informing them that the patient has not attended for the requested procedure and the referral is cancelled from the RIS.Back to Table of Contents Section 2 – Pre-Procedure for outpatients onlyPre Admission ClinicOn arrival at preadmission clinic the patient will have:The Medical Imaging Angiography Record (Attachment A) commencedbloods takenECG/ Vital signs performeda consult by the Vascular teamdiscussion around fasting requirements and medicationsinformation given regarding Day of Admission procedure.Patient assessment for Nurse Sedation includes:Prior illnesses and conditions (refer to indications and exclusion criteria as stated on online request form)medication historymedication allergies (recorded on Medication Chart)relevant pathology results for the procedure and patient condition e.g. platelet count prior to lumbar punctureprevious sedation experiences and medications usedaccurate weight (recorded on Medication Chart)Adequate preparation and education of the patient (and /or carer) should be providedAn anaesthetist consult is required if the patient:is booked for a General Anaesthetic orhas sleep apnoea (airway issues) or has had a previous need for General Anaesthesia is a DOSA patient with multiple co morbiditiesat the recommendation from previous radiologist request or at the request of the treating team.Back to Table of ContentsSection 3 – Day of ProcedureInpatientsWard based Inpatients:Patient is transferred from ward to Medical Imaging Day ward with or without nurse escort depending on the patient needs such as;patient co-morbiditiesattachments (IV fluids/ medications)Clinical Handover from ward nurse escort to Medical Imaging Day ward nurse Consent is performed pre-procedurally by Interventional RadiologistPre-interventional checklist to be completed by ward staffDay of Surgery Admission (DOSA)Patients who will require an overnight stay in a ward will present at main admission in the hospital foyer at 7:30am and be escorted to the Medical Imaging Day ward. Following arrival at Medical Imaging Day ward patients will:Change into theatre gownhave a cannula inserted have site prepared by ward staff which includes shaving the groin or neck as requiredhave bloods checked and recorded in noteshave medical admission completed by treating teamhave a nursing admission documented on the Angiography Record #65604 (Attachment A)have the electronic patient safety system “STOP/GO” commenced with information such as cannulation, blood results, diabetes status and allergies documented.wait for transfer to Interventional Radiology suite in bedhave a written consent completed and explained by Interventional Radiology Registrar/ Radiologist.Out PatientsDay CasesPatients who are expected to be discharged home at end of the day will present to Medical Imaging Admission at 8:00am and be escorted to the Medical Imaging Day ward. On arrival at the Medical Imaging Day ward patients will:change into theatre gownhave a cannula insertedhave site prepared by shaving the groin or neck as per entry pointhave bloods checked and recorded in noteshave a nursing admission documented on the Angiography Record #65604 (Attachment A)have the electronic patient safety system ‘STOP/GO’ is commenced with information such as cannulation, blood results, diabetes status and allergies.wait for transfer to Interventional Radiology suite in bedhave a written consent completed and explained by Interventional Radiology Registrar/ Radiologist.In Medical Imaging Day ward or Interventional Radiology SuiteMedical Imaging Angiography Record #65604 (Attachment A) continues from ‘Day of Procedure’Baseline Modified Early Warning System (MEWS) and neurovascular observations are attended to and recorded on the patients MEWs chart and Neurovascular Observation Chart #60320. Confirm patency of cannula in Medical Imaging Day ward by nursing staff. The electronic patient safety system ‘STOP/GO’ is commenced with information such as cannulation, blood results, diabetes status and allergies. Started in Day ward and completed in Angiography Patient is transferred to the Interventional Radiology Suite and a handover is given to Interventional staff by Medical Imaging Day ward staff including;Utilising the consumer record to cross-check information, using the three unique identifiers as per CHHS Patient Identification and Procedure Matching Policy;Documentation of all important findings or changes of condition/care, including reference to medications, falls and pressure injury risk and risk of deterioration;Ensure, where possible, that parents/ carers are included in handover discussionsInterventional Radiologist gains written informed consent prior to procedure Team Time Out performed.Inpatient/ Out patient has pre intervention check completed, (Attachment C) and Medical Imaging Angiography Record #65604 (Attachment A). Any other co-morbidities relating to the particular patient. Other relevant information such as enduring power of attorney (EPOA) or Not For Resus (NFR) or Guardianship OrdersBack to Table of ContentsSection 4 – In the Interventional Radiology SuiteTheatre attire is required by all staff in the Angiography Room. Once the patient arrives in Interventional Radiology unit a ‘TIMEOUT’ is carried out by the Radiographer, Radiologist and Registered Nurse to ensure correct patient, correct site and correct procedure as per CHHS Patient Identification and Procedure Matching Procedure.Select patient on RIS & conduct Time Out ID MOMENT in the procedure room with the patient present and immediately before commencing the procedure, the senior clinician conducts a ‘time out’ as a single operator or leads the team in a ‘time out’ and verbally confirms: Correct patient is presentCorrect procedure to be performedCorrect side/site is identified and markedConsent is cross-checked with proposed procedure and where appropriate for the procedure:Correct patient details are on the imaging deviceCorrect previous images are displayedImplant/equipment/medication is available and correct.Patient is transferred across onto the Interventional Radiology table, utilising transfer equipment and extra staff to assistObservations of pulse rate, respiratory rate, oxygen saturation and blood pressure monitored at least every 5-10 minutes during the procedureSedation score rating documented on observation chart every 5 minutesSedation Nurse must be deemed competent through the Medical Imaging Sedation Nurse Self Directed Learning Package (SDLP) and competency test.Interventional Radiologist/registrar prescribe sedation pre operatively unless in urgent cases. When the Interventional Radiologist/ Fellow/ Registrar is unable to provide a written order prior to the procedure, the sedation nurse can obtain a verbal order ...When the Interventional Radiologist/ Fellow/ Registrar are unable to provide medication order for sedation, the sedation nurse follows CHHS15/086 (Medication Handling Policy) subsection 2.5.6 (Verbal and Telephone Medication Orders) where verbal order is taken from Radiologist/ Fellow and scribes dosages and time intervals along with observationsInterventional Radiologist signs order at end of procedureScrub Nurse will scrub in and prepare Interventional Radiology trolley following the aseptic non touch technique CHHS Aseptic Non Touch Technique and Australian College of Operating Room Nurses (ACORN) standards.All scrub staff are required to completeAseptic Technique trainingScrubbing Gowning & Gloving Self Directed Learning Package and be assess as competentPatient prepared and draped as per ACORN standards for interventional surgical procedure.Alert: Chemotherapy precautions are to be carried out by staff, if the patient is undertaking or has had recent chemotherapy. Back to Table of Contents Section 5 – Procedures Procedures Performed in the Interventional SuiteAdrenal Vein SamplingIVC Filter InsertionAngiogram PelvisIVC Filter RemovalAngiogram AbdomenNephrostomy InsertionAngiogram Aorta/Femoral AngiogramNephrostomy ExchangeAngiogram Head & NeckNephrostomy Removal-JJ in SituAngiogram Lower LimbNJ Tube ChangeAngiogram RenalNJ Tube InsertionAngiogram ThoraxOvarian VenogramAngiogram Upper LimbPetrosal venous samplingPercutaneous Transluminal Angioplasty (PTA)PICC Line InsertionBalloon placement/ embolisation for placenta accretaPortacath insertionBiliary Drain (Insertion/ exchange/ removal)Radiofrequency AblationBiliary Metal Stent InsertionRemove Foreign BodyBiopsyRenal Calculus RemovalPercutaneous Transhepatic Cholangiogram (PTC) plus Drain InsertionRenal Renins SamplingEmbolisation (Neuro)Trans Arterial Chemo Embolisation (TACE)EmbolectomyTesticular VenogramEmbolisation varicoceleThrombolysisEmbolisation varicose veins/ pelvic congestionTransinterjugular Intrahepatic portosystemic Shunt (TIPS) Embolisation(General)Tunnelled Line - DialysisERCP in Angio SuiteTunnelled Line - NON DialysisEVAR abdominal aortic aneurysmUreteric JJ Stent Insertion/ RemovalEVAR fenestratedUterine VenogramEVAR thoracic aortic aneurysmVenogram- AbdoFistula angioplastyVenogram- Lower LimbFistulagram/ LoopogramVenogram- PelvicGastrostomy- ChangeVenogram- ThoraxGastrostomy- CheckVenogram- Upper LimbGastrostomy- InsertComputerised Tomography InterventionalHysterosalpingogram2D PerfusionConsultation (Initial/ Followup)Thrombolysis (Neuro)Vascular Stent InsertionEquipment Refer to Procedure setup card & Radiologists preference card for interventional procedures, stored electronically in the Interventional Radiology Unit preparation room. Equipment set up for procedures listed in Section 5.1 will be according to each Interventional Radiologist’s preference. Angiography RadiographerResponsible for safe and effective operation of imaging equipment and imaging applications. This encompasses:Radiation Safety and Protection (ALARA Principle)Radiation Safety Management PlanImage acquisition and post ProcessingData tracking and Procedure CodingAudit Data Collection.Back to Table of ContentsSection 6 – Post ProcedureThe Registered Nurse will complete the ‘Interventional Radiology’ procedure sticker in the patient’s notes. Ensure the Radiologist signs the written and/ or verbal medication orders and documents post-procedural orders.Patient is transferred to their bed on a pat slide and escorted by either the Interventional Radiology scrub or sedation nurse to Medical Imaging Day wardHandover from Angiography nurse to Medical Imaging Day ward staff Following Medical Imaging Angiography Record #65604 (Attachment A) and continuing from “Post Procedural Observations”, Interventional Radiology Record should be completed and placed in the patient’s clinical recordThe arterial puncture site is also examined as part of the handover for any signs of swelling or bruising following below criteriaIf manual compression applied – 15 minutely for 2 hours then 30 minutely for 4 hrs unless otherwise instructed by the radiologistIf a Closure Device is used – 15 minutely for 1 hour then 30 minutely for 1 hour unless otherwise instructed by the radiologist.ALERT: Post Procedure Escalation of Arterial BleedsOnly Direct Digital Pressure (DDP) is to be used for vascular patients when applying pressure to puncture sites, (DO NOT USE SANDBAGS OR FLUID BAGS)Arterial puncture sites can, and do bleed - EARLY INTERVENTION AND DOCUMENTATION IS VITAL TO ACHIEVE POSITIVE OUTCOMESIf there is no response by the Vascular Team (Including Radiologist) AND/OR THE PATIENT IS DETERIORATING - continue with direct digital pressure over the puncture site >> CALL METBack to Table of ContentsSection 7 – DischargeFollowing the Medical Imaging Angiography Record #65604, the following ‘Discharge Criteria’ will be completed: (Attachment A):Post procedure educationNo swelling or bleeding at procedural puncture site observedPuncture site observations are charted in patient notes Pain Score <4IV cannula will be removed if patient is going homePatient given post procedural care instructionAngioseal information record given to the patient Informed verbally about care of puncture site. Patient has follow up appointment, if necessaryEnsure all patient belongings including X-ray and own medications are with the patientTransferred to ward time indicatedIn-patients require ward escort to go back to wardPatient signature on discharge with date and timeOn discharge, ensure patient is escorted with a carer. Inpatients:Ward patients are monitored until vital signs have stabilised and are then transferred back to the ward 30 minutes post procedure, Transport is organised with ward services and contact is made with destination ward nurse prior to transportPatient escorted by Medical Imaging nurse back to ward, where clinical handover is conducted Out-patient:Day care:Patients are monitored until vital signs have stabilised in Medical Imaging Day ward or until discharged at end of day as per discharge instructionPatient discharged from Medical Imaging Day ward utilising above discharge criteriaDay of Surgery Admission (DOSA):Patients are monitored until vital signs have stabilised in Medical Imaging Day ward and are then transferred to the destination ward as per bed management arrangements.Transport is organised through ward services for transfer to destination wardWard is notified that patient escort is requiredPatient transferred to destination ward and clinical handover given If patient has brought in own medications, ensure all medications are transferred with the patient.Back to Table of Contents Implementation Included in New Staff Orientation ManualStanding item at Angiography Meeting reviewing documentRelated Policies, Procedures, Guidelines and LegislationPoliciesRadiation Safety Management Plan (23/01/2015) 7.2, p 22 of 36Non Critical Patients CHHS14/039Procedural Sedation SOP TCH07:005Escorting Patients Policy TCH10:008Clinical Handover Policy CHHS15/069 Healthcare Associated Infections CHHS15/072, subsection 2.9 “Code of Dress or Attire in Restricted/Semi restricted Procedure Areas” Patient Identification and Procedure Matching CHHS14/052 Central Venous Access Device (CVAD) Management – Children, Adolescents and Adults (NOT Neonates) CHHS13/572Aseptic Non Touch Technique CHHS14/011Personal Protective Equipment SOP Document Number CHHS12/251Clinical Handover, CHHS15/069Guidelines Radiation Safety Management Plan November 2014Australian College of Operation Room Nurses (ACORN), 2014-2015Australian Radiation Protection and Nuclear Safety Agency (ARPNSA), publication No. 14.1, 2008The Royal Australian and New Zealand College of Radiologists (RANZCR) Standards of Practice, 2007LegislationRadiation Protection Act 2006 (A2006-33)Back to Table of ContentsDefinition of TermsAs Low As Reasonably Achievable (ALARA), is an acronym for an important principle in exposure to radiation and other occupational health risks. The aim is to minimize the risk of radioactive exposure or other hazard while keeping in mind that some exposure may be acceptable in order to further the task at hand.ACORN: The ACORN standards provide a minimum standard of practice for perioperative nurses, and requirements for visitors and healthcare facilitiesBack to Table of ContentsSearch Terms Angiography Suite, Angiogram, Angioplasty, Embolisation for placenta accrete, Biliary Calculus Removal, Biliary Drain Change, Biliary Metal Stent, Cholangiogram EmbolisationEmbolisation varicocele, Embolisation, ERCP, EVAR, Fistula angioplasty, Fistulagram, Gastrostomy-Hysterosalpingogram, Interventional Radiology, IVC Filter, Lumbar Puncture – Nephrostomy, NJ Tube Change, NJ Tube Insertion, Ovarian Venogram, Petrosal venous sampling, PICC Line Insertion, Portacath insertion, PTC & Drain Insertion, Radiofrequency Ablation, Remove Foreign Body, Renal Calculus Removal, Renal Renins Sampling, SialogramTACE-chemoembolisation, Testicular Venogram, Thrombolysis dialysis fistula, TIPS-ortocaval shunt, Tunnelled Line, Ureteric JJ Stent Insertion, Uterine Venogram, Venogram, Vertebroplasty Arterial Bleeds, Radiation Safety Management Plan, e-Orders, ALARA Principle, Did Not Attend (DNA)Back to Table of ContentsAttachmentsAttachment A: Medical Imaging Angiography Record #65604Attachment B: Paper Referral F00085(0902)51163Attachment C: Medical Imaging Pre Interventional ChecklistAttachment D: Radiology Preparation Orders and Check List #60370Disclaimer: This document has been developed by ACT Health, <Name of Division/ Branch/Unit> specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.Date AmendedSection AmendedApproved ByEg: 17 August 2014Section 1ED/CHHSPC ChairAttachment A: Medical Imaging Angiography Record #65604Attachment B: Paper Referral F00085(0902)51163Attachment C: Medical Imaging Pre Interventional ChecklistAttachment D: Radiology Preparation Orders and Check List #60370 ................
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