Inside M.D. Anderson’s Interventional Radiology Patient Safety Program

January 12, 2012

Researchers report on a program aimed at minimizing radiation-induced skin injuries.

Adding a patient-radiation safety program is straightforward, takes little infrastructure and few resources, and benefits providers as well as patients, say researchers at the University of Texas M.D. Anderson Cancer Center’s Division of Diagnostic Imaging. Their report appears in the January-February 2012 edition of Radiographics.

Joseph R. Steele, MD, and colleagues implemented the program in July 2009; by September 2010, they had monitored cumulative radiation doses (CD) for 3,500 interventional radiology procedures. A small fraction - 63 procedures - sent patients over a CD of 3,000 milligray (mGy), with four patients exceeding 7,000 mGy. The program’s principal aim was to minimize radiation-induced skin injuries.

The M.D. Anderson program combined pre-procedure evaluation and counseling, monitoring during procedures, and post-procedure documentation and counseling with the guidelines of the National Cancer Institute and the Society of Interventional Radiology.

Going in, the researchers considered the following procedures to be as¬sociated with an increased risk for skin injury: any embolization procedure, biliary drainage, transjugular intrahepatic portosystemic shunt placement, and vascular interventional procedures that require balloon angioplasty or stent placement.

The radiation safety program involved taking different actions at different radiation thresholds. At a cumulative does of 2,000 mGy, technologists notified the radiologist, who ensured that radiation was being used sparingly but continue as normal. As cumulative dose climbed, the checks and balances become more intense, with “all possible dose-reduction methods” being used at 8,000 mGy.

Technologists recorded CD, dose-area product (DAP), total fluoroscopy time, and the number of rotational angiography acquisitions, which are used to reconstruct CT images.

Team members reviewed an interventional radiology post-procedure radiation dose information sheet with patients who received a CD of more than 3,000 mGy. The sheet showed the specific anatomic area that should be examined for changes and the signs of deterministic injury, such as a red area the size of a hand; flaking, sunburn-like skin; localized hair loss; and constant itching at the affected area. Patients were encouraged to contact their physician if they have any questions, and a one-month follow-up telephone appointment was made before the patient was discharged.

Between July 20, 2009, when the program was implemented, and September 1, 2010, complete dose information was recorded for 65 percent (3,701 of 5,718) of all interventional radiologic procedures done at M.D. Anderson. The technologist compliance rate was 60 percent during the first four months after the program was launched, dropping to less than 50 percent for the fourth and fifth months. To address this, technologists were given in-service lectures about the program’s importance.

Because no skin changes were seen in patients who received a CD of 3,000 mGy, the threshold for patient follow-up was later increased from 3,000 mGy to 5,000 mGy. Increasing the threshold is expected to decrease the workload on mid-level providers and reduce patient anxiety.

There were also unexpected benefits, Steele and colleagues reported. Patients who did end up with radiation-induced skin injuries weren’t surprised by it. In addition, they concluded, “Conversations among interventional radiology staff at our institution have revealed that focusing on this specific aspect of patient safety has fostered a culture of safety.”