northern california sgna meeting september 22, 2012

Northern CaliforniaNorthern California

SGNA MeetingSGNA Meeting

September 22, 2012September 22, 2012

Radiation safetyRadiation safety

in in thethe

ERCP suiteERCP suite

Disclosure StatementDisclosure Statement

Product Specialist forProduct Specialist for

Core Medical ImagingCore Medical Imaging

Distributor of Omega’s E-view Distributor of Omega’s E-view system for ERCP studiessystem for ERCP studies

Radiation Safety in the ERCP suiteRadiation Safety in the ERCP suite

EndoscopicEndoscopic

RetrogradeRetrograde

CholangioPancreatographyCholangioPancreatography

FluoroscopyFluoroscopy

Radiation Safety in the ERCP suiteRadiation Safety in the ERCP suite

Objectives:Objectives:

To discuss: To discuss:

Four equipment configurationsFour equipment configurationsBasics of x-rayBasics of x-ray

Scatter radiationScatter radiation Minimize radiation doseMinimize radiation dose

Radiation Safety in the ERCP suiteRadiation Safety in the ERCP suite

Today’s goal:Today’s goal:

Understand fluoroscopy to:Understand fluoroscopy to:Compliment examCompliment exam

Minimize radiation exposure Minimize radiation exposure

Radiation Safety in the ERCP suiteRadiation Safety in the ERCP suite

Why are these goalsWhy are these goals

important to aimportant to a

Nurse?Nurse?

Radiation Safety in the ERCP suiteRadiation Safety in the ERCP suite

Radiating the patientRadiating the patient

is part of is part of

““Patient Care!Patient Care!” ”

Radiation Safety in the ERCP suiteRadiation Safety in the ERCP suite

What is Fluoroscopy?What is Fluoroscopy?

(in English) (in English)

Radiation Safety in the ERCP suiteRadiation Safety in the ERCP suite

What is Fluoroscopy?What is Fluoroscopy? Low dose x-ray imageLow dose x-ray image Taken at 30,15 or 7.5 times/secTaken at 30,15 or 7.5 times/sec Displayed at 30 frames/secDisplayed at 30 frames/sec

Radiation Safety in the ERCP suiteRadiation Safety in the ERCP suite

2 Radiation items 2 Radiation items you need to know:you need to know:

#1 Less is better#1 Less is better#2 Inverse square law#2 Inverse square law

Radiation Safety in the ERCP suiteRadiation Safety in the ERCP suite

2 Radiation items 2 Radiation items

you need to know:you need to know:

#1 Radiation - Less is better#1 Radiation - Less is better

(= image quality)(= image quality)

Radiation Safety in the ERCP suiteRadiation Safety in the ERCP suite

Radiation: the opposite of chocolateRadiation: the opposite of chocolate

Radiation Safety in the ERCP suiteRadiation Safety in the ERCP suite

2 Radiation items 2 Radiation items

you need to know:you need to know:

#2 Inverse square law#2 Inverse square law

Radiation Safety in the ERCP suiteRadiation Safety in the ERCP suite

Inverse square law:Inverse square law:

2 x the distance =’s2 x the distance =’s

4 x the radiation4 x the radiation

Radiation Safety in the ERCP suiteRadiation Safety in the ERCP suite

Inverse square law:Inverse square law:

3 x the distance =’s3 x the distance =’s

9 x the radiation9 x the radiation

Radiation Safety in the ERCP suiteRadiation Safety in the ERCP suite

Application of Inverse Square lawApplication of Inverse Square law

Image Intensifier - close to patient Image Intensifier - close to patient as possibleas possible..

X-ray tube – far away from patient X-ray tube – far away from patient as possible.as possible.

Radiation Safety in the ERCP suiteRadiation Safety in the ERCP suite

Equipment Equipment ConfigurationsConfigurations

Radiation Safety in the ERCP suiteRadiation Safety in the ERCP suite

Radiation Safety in the ERCP suiteRadiation Safety in the ERCP suite

4 equipment configurations4 equipment configurations

do 98.56% of all ERCP’sdo 98.56% of all ERCP’s

Radiation Safety in the ERCP suiteRadiation Safety in the ERCP suite

47.07% of exams47.07% of exams

ERCP Modalities - Portable C-armERCP Modalities - Portable C-arm

Radiation Safety in the ERCP suiteRadiation Safety in the ERCP suite

Portable C-armPortable C-armAdvantages:Advantages: Least cost Least cost

(~$225,000)(~$225,000) Every hospital has Every hospital has

1 or 2 or 31 or 2 or 3 Tube angulationTube angulation

Tube angulationTube angulationImage viewed straight on

Cystic Duct superimposed

C-Arm angled to view

Cystic Duct

Radiation Safety in the ERCP suiteRadiation Safety in the ERCP suite

Portable C-armPortable C-armDis-advantages:Dis-advantages: Image qualityImage quality Radiation doseRadiation dose Slow/hard to useSlow/hard to use

Radiation Safety in the ERCP suiteRadiation Safety in the ERCP suite

ERCP Modalities - Rad/Fluoro roomERCP Modalities - Rad/Fluoro room

28.52% of exams28.52% of exams

Radiation Safety in the ERCP suiteRadiation Safety in the ERCP suite

Rad/Fluoro roomRad/Fluoro roomAdvantages:Advantages: Image qualityImage quality Radiation doseRadiation dose Moderate expenseModerate expense ($300K - $325K)($300K - $325K)

Radiation Safety in the ERCP suiteRadiation Safety in the ERCP suite

Rad/Fluoro roomRad/Fluoro room

Dis-advantages:Dis-advantages: No tube angulationNo tube angulation Non elevating tableNon elevating table Patient orientationPatient orientation

Radiation Safety in the ERCP suiteRadiation Safety in the ERCP suite

ERCP Modality - Multi Purpose roomERCP Modality - Multi Purpose room

17.24% of exams17.24% of exams

Radiation Safety in the ERCP suiteRadiation Safety in the ERCP suite

Multi Purpose roomMulti Purpose roomAdvantages:Advantages: Image qualityImage quality Radiation doseRadiation dose Tube angulationTube angulation Elevating tableElevating table

Radiation Safety in the ERCP suiteRadiation Safety in the ERCP suite

Multi Purpose roomMulti Purpose roomDis-advantages:Dis-advantages: Equipment costEquipment cost ($550K+)($550K+) ComplexityComplexity Room sizeRoom size

Radiation Safety in the ERCP suiteRadiation Safety in the ERCP suite

2.72% of exams2.72% of exams

ERCP ModalitiesERCP ModalitiesDedicated designedDedicated designed

Radiation Safety in the ERCP suiteRadiation Safety in the ERCP suite

Dedicated designed Dedicated designed Advantages:Advantages: Image qualityImage quality Radiation doseRadiation dose Tube angulation Tube angulation Elevating tableElevating table

Radiation Safety in the ERCP suiteRadiation Safety in the ERCP suite

Dedicated designedDedicated designedDis-advantages:Dis-advantages: Cost $400KCost $400K

Radiation Safety in the ERCP suiteRadiation Safety in the ERCP suite

Scatter Radiation Scatter Radiation

Why is it important?Why is it important?

Radiation Safety in the ERCP suiteRadiation Safety in the ERCP suite

WGO 2009WGO 2009

““For endoscopists and staff, the major For endoscopists and staff, the major source of x-ray exposure is scattered source of x-ray exposure is scattered radiation from the patient, not the primary x-radiation from the patient, not the primary x-ray beam.” ray beam.”

Radiation Safety in the ERCP suiteRadiation Safety in the ERCP suite

<1% Table top<1% Table top

98+% Patient98+% Patient

<1% Image Int.<1% Image Int.

Radiation Safety in the ERCP suiteRadiation Safety in the ERCP suite

Scatter Radiation Scatter Radiation

How to minimize itHow to minimize it

Radiation Safety in the ERCP suiteRadiation Safety in the ERCP suiteMinimize Radiation DoseMinimize Radiation Dose

Lead ShieldingLead Shielding

Radiation Safety in the ERCP suiteRadiation Safety in the ERCP suite

Table drape for Table drape for nurses nurses

Radiation Safety in the ERCP suiteRadiation Safety in the ERCP suiteMinimize Radiation DoseMinimize Radiation Dose

Pay attentionPay attention to to

the fluoro dosethe fluoro dose

readout devicereadout device

Radiation Safety in the ERCP suiteRadiation Safety in the ERCP suiteMinimize Radiation DoseMinimize Radiation Dose

Required in 2006Required in 2006

Display resultsDisplay results

WGO GuidelinesWGO Guidelines

http://www.worldgastroenterology.org/assets/downloads/en/http://www.worldgastroenterology.org/assets/downloads/en/pdf/guidelines/pdf/guidelines/23_wgo_radiation_protection_in_endo_suite_en.pdf23_wgo_radiation_protection_in_endo_suite_en.pdf

WGO GuidelinesWGO Guidelines

Level 1: high resource levelsLevel 1: high resource levels

Level 2: average resource levelsLevel 2: average resource levels

Level 3: minimum resource levelsLevel 3: minimum resource levels

WGO GuidelinesWGO Guidelines

Use of proper technique to Use of proper technique to minimize the radiation dose to the minimize the radiation dose to the patient (e.g., keeping the x-ray tube patient (e.g., keeping the x-ray tube as far away from the patient as as far away from the patient as possible and the image receptor as possible and the image receptor as close as feasible, …) close as feasible, …)

Radiation Safety in the ERCP suiteRadiation Safety in the ERCP suite

SummarySummary1) Radiation – less is better1) Radiation – less is better2)2) Use Inverse square law Use Inverse square law3) Proper shielding3) Proper shielding

Radiation Safety in the ERCP suiteRadiation Safety in the ERCP suite

Questions?Questions?

Radiation Safety in the ERCP suiteRadiation Safety in the ERCP suite

ReferencesReferencesSlide # 10 – WGO Practice Guideline: Slide # 10 – WGO Practice Guideline:

Radiation protection in the endoscopy suiteRadiation protection in the endoscopy suite

Slide # 20 – Survey conducted by Don Dockter Slide # 20 – Survey conducted by Don Dockter

Slide # 21 – Survey conducted by Don DockterSlide # 21 – Survey conducted by Don Dockter

Slide # 25 – Survey conducted by Don DockterSlide # 25 – Survey conducted by Don Dockter

Slide # 28 – Survey conducted by Don DockterSlide # 28 – Survey conducted by Don Dockter

Slide # 31 – Survey conducted by Don DockterSlide # 31 – Survey conducted by Don Dockter

Radiation Safety in the ERCP suiteRadiation Safety in the ERCP suite

ReferencesReferencesSlide # 36 – Mr. James Princehorn, President Omega MedicalSlide # 36 – Mr. James Princehorn, President Omega Medical

– – WGO Practice Guideline:WGO Practice Guideline:

Radiation protection in the endoscopy suiteRadiation protection in the endoscopy suite

Slide # 41Slide # 41 – 2– 21CFR, part 1020.32 1CFR, part 1020.32 allall diagnostic x-ray device must diagnostic x-ray device must

display Entrance Air Kerma Rate, Accumulated Airdisplay Entrance Air Kerma Rate, Accumulated Air

Kerma, and Accumulated Fluoro Time.Kerma, and Accumulated Fluoro Time.

Slide # 44 – WGO Practice Guideline:Slide # 44 – WGO Practice Guideline:

Radiation protection in the endoscopy suiteRadiation protection in the endoscopy suite