Written by Rhiannon Anderson and Judith Buckland

10 Steps to Building a Nuclear QI Program to Meet ALARA Recommendations

This month we reviewed radiation safety and patient centered nuclear cardiology protocols. To close out our March focus on nuclear cardiology, this week we will review IAC nuclear accreditation requirements for on-going Quality Improvement (QI) and provide easy steps to creating your own program.

Quality Improvement

The quality improvement program was updated in 2016.  Facilities must have a quality improvement process in place to evaluate Quality Improvement (QI) measures.  The assessments are an ongoing process with monthly or quarterly review of results. The facility must have a minimum of two QI meetings per year. At least one of those meetings must be used to discuss the QI analyses and any QI-related topics.

The IAC Nuclear QI program must include the following measures:

  • Test appropriateness
  • Technical quality and safety of the imaging
  • Interpretive quality review
  • Report completeness and timeliness
  • Correlation

Test Appropriateness

The facility must evaluate tests as appropriate/usually appropriate, may be appropriate or rarely appropriate/usually not appropriate. AUC should be measured using consecutive exams over a two-three week period in order to evaluate 5% of the annual volume. For smaller volume facilities, use a minimum of 30 consecutive exams.

The Centers for Medicare and Medicaid (CMS) is in the process of implementing an aspect of the Protecting Access to Medicare Act (PAMA) of 2014 that will introduce a new framework for applying AUC. In 2018, PAMA will require ordering physicians to consult AUC using a CMS-approved CDSM with nuclear cardiology.  We will provide additional updates on this CMS requirements as more information is made available.

Technical Quality Review

Many different suggestions for technical quality review are provided by IAC and can be reviewed in their standards.  One of the measures listed is ‘dose verification of administered radioactive dose to prescribed dose listed in protocol’.   We are encouraging our clients to focus on radiation safety and this QI measures is a great place to start!  CardioServ has further developed this technical quality improvement measure with a goal to meet ASNC’s ALARA recommendations of < 9 mSv in at least 50% of studies.

10 Steps to Building a Nuclear QI program to Meet ALARA Recommendations

If you have the ability to quickly implement changes, the best practice is to use a stress/rest protocol and have stress-images reviewed by a physician to see if the rest-test is necessary.  If the stress is normal and if clinically indicated the rest portion of the study can be canceled.  If you do not have the ability to drive change quickly within your facility, you should start to track data. Remember, it is easier to drive change when you have data to review. Here are 10 steps you could take to start gathering data to present to your RSO or Nuclear Cardiology Director:

  1. Establish your baseline by reviewing your current protocol for dosing amounts
  2. Track 30 consecutive patients to ensure they are receiving this dose within + 10%
  3. Calculate the effective radiation dose for each patient and determine if you met the ASNC ALARA goal of < 9 mSv in at least 50% of studies. (See Essentials Steps to Creating Patient Centered MPI Protocols)
  4. Review your current Tc-99m dosing amounts and see if you can incorporate patient centered protocols by reducing your stress/rest dose based on patient body habitus and BSA
  5. If you are not already doing so, switch to a STRESS / REST protocol instead of rest/stress protocol
  6. Track another 30 consecutive patients and calculate the effective radiation dose for each patient and determine if you met the ASNC ALARA goal of < 9 mSv in at least 50% of studies
  7. Track how many patients had a negative stress-test and then received an unnecessary negative rest-test
  8. Recalculate what the overall effective radiation dose would have been if they did not receive the rest-test
  9. If these patients had NOT received their rest-test would you have met the ASNC ALARA goal of < 9 mSv in at least 50% of studies?
  10. Present these findings to your RSO or your Nuclear Medical Director

Interpretive Quality Review

Your QI Plan must also include evaluating the quality and accuracy of Interpretation.  Two ways to accomplish this measure would be through peer review and/or clinical correlation.

Reporting Requirement Updates

Report Completeness

Accredited facility should have standardized reporting in place.  The 2016 IAC Nuclear Standards update included additions to some mandatory components of a complete MPI report and include:

  • Patient information should include height and weight or BMI (in addition to patient’s first and last name, gender and age/DOB)
  • Technique:  Be sure to describe the testing protocol used (e.g., rest/stress vs. stress/rest, one-day vs. two-day, gated, first pass, red cell labeling method, 3-phase, flow, blood pool, attenuation correction method, etc.)
  • Note if there was a deviation from facility’s protocol
  • Functional Results:
    • Quantitative left ventricular (LV) ejection fraction
    •  Overall LV function (normal, reduced [mild, moderate or severe] or hyperdynamic)
    • Regional wall motion abnormalities
    • All perfusion defects must be described, when a defect is due to attenuation/artifact this must also be identified as such
  • Final impressions should include:
    • Summary of perfusion (normal, equivocal, abnormal, ischemia, or infarction)
    • Summary of function (normal, equivocal, abnormal)
    • Should resolve any discrepancies

Turnaround Time

Just a reminder that for all MPI reports an interpretation must be available within one working day of the examination.  (An interpretation may be in the form of paper, digital storage or accessible voice system.)  Critical findings must be communicated to the referring physicians as quickly as clinically indicated and a record of the communication must be maintained.

The final signed report must be transmitted to the referring health care provider within two working days.  In regards to signatures be aware that if the report is signed manually, the signature MUST be dated.  If the report is signed electronically, the signatures must be password protected with sign off only by an interpreting physician. The signature must indicate it is electronically recorded and be electronically date/time stamped.

Report Completeness and Timeliness QI Measure

All facilities must track report completeness and timeliness.  There is not set number of studies that must be monitored.  Your facility may choose how many as long as this is an ongoing measure.  Your review should include ensuring final reports include all mandatory reporting components and that the turnaround time is compliant.

5 Steps to Developing Your Report Completeness QI Measure

  1. Establish a baseline for compliance by pulling 5 – 10 reports per physician
  2. If there are issues with report completeness determine root cause – Is there an issue with the template missing fields?
  3. Address root causes – add all mandatory fields to the reporting template, add a “cheat sheet” in the physician reading room, etc.
  4. Turnaround time – ensure all physicians are aware of turnaround time requirements
  5. Track regularly and provide physicians with turnaround time results

We covered a lot of material in this week’s blog regarding creating a complaint IAC Nuclear QI Program with a focus on lowering radiation dose exposure.  Feel free to contact us with questions and/or ask for help.  We hope we inspired you to make it your personal goal to reduce radiation exposure to your patients.  We can all make a difference one facility at a time.

accreditationALARAIAC StandardsICANLinterpretive qualityintersocietal accreditation commissionnuclearnuclear cardiologyQI maintenancequality improvementreport completenesstechnical qualitytest appropriatenessturnaround time


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