Guidelines for establishing a quality improvement program in interventional radiology

Image-guided renal parenchymal biopsies- how we do it

This paper is a multi-institutional review of image-guided renal parenchymal biopsies. Among the topics covered are indications, preprocedural considerations, biopsy technique, complications, and postprocedural management. Both native kidney and transplant kidney biopsies are considered in this review.

French Interventional Radiology Centers' Uptake of Transradial Approach and Outpatient Hepatocellular Carcinoma Intra-Arterial Treatments

PURPOSE

This study aims to investigate the uptake of transradial approach (TRA) and outpatient setting for transarterial chemoembolization (TACE) and transarterial radioembolization (TARE) in the treatment of hepatocellular carcinoma (HCC) among French interventional radiology centers.

MATERIALS AND METHODS

This cross-sectional study was based on a 34-question survey assessing center activity, radial access, and outpatient care. The survey was developed by a working group, tested by two external experts, and distributed to active members of two French radiological societies via a web-based self-reporting questionnaire in March 2022. The survey remained open for eight weeks, with two reminder emails sent to non-responders. Only one answer per center was considered.

RESULTS

Of the 44 responding centers, 39% (17/44) performed TRA for TACE and/or TARE, with post-procedure patient comfort as main motivation. Among the 27 centers not performing TRA, 33% (9/27) reported a lack of technical experience, but all 27 intended to adopt TRA within two years. Only six centers performed TACE or TARE in an outpatient setting. Reasons limiting its implementation included TACE for HCC not being a suitable intervention (61%, 27/44) and organizational barriers (41%, 18/44). Among centers not performing outpatient TACE or TARE, 34% (13/38) said "No," 34% (13/38) said "Maybe," and 32% (12/38) said "Yes" when asked about adopting it within two years.

CONCLUSION

French interventional radiologists have low TRA uptake for HCC treatment, but TRA adoption potential exists. Respondents were uncertain about performing TACE or TARE in an outpatient setting within a 2-year horizon.

Looking Into the Future: The Current and Future State of IR in Canada

This review explores the priorities and future opportunities of interventional radiology in Canada.

CIRSE Clinical Practice Manual

Background

Interventional radiology (IR) has come a long way to a nowadays UEMS-CESMA endorsed clinical specialty. Over the last decades IR became an essential part of modern medicine, delivering minimally invasive patient-focused care.

Purpose

To provide principles for delivering high quality of care in IR.

Methods

Systematic description of clinical skills, principles of practice, organizational standards and infrastructure needed for the provision of professional IR services.

Results

There are IR procedures for almost all body parts and organs, covering a broad range of medical conditions. In many cases IR procedures are the mainstay of therapy, e.g. in the treatment of hepatocellular carcinoma. In parallel the specialty moved from the delivery of a procedure towards taking care for a patient’s condition with the interventional radiologists taking ultimate responsibility for the patient’s outcomes.

Conclusions

The evolution from a technical specialty to a clinical specialty goes along with changing demands on how clinical care in IR is provided. The CIRSE Clinical Practice Manual provides interventional radiologist with a starting point for developing his or her IR practice as a clinician.

Adherence to the RIGHT statement in Society of Interventional Radiology guidelines

Context

The Reporting Items for Practice Guidelines in Health Care (RIGHT) Statement was developed by a multidisciplinary team of experts to improve reporting quality and transparency in clinical practice guideline development.

Objective

To assess the quality of reporting in clinical practice guidelines put forth by the Society of Interventional Radiology (SIR) and their adherence to the RIGHT statement checklist.

Methods

In March 2018, using the 22 criteria listed in the RIGHT statement, two researchers independently documented adherence to each item for all eligible guidelines listed by the SIR by reading through each guideline and using the RIGHT statement elaboration and explanation document as a guide to determine if each item was appropriately addressed as listed in the checklist. To qualify for inclusion in this study, each guideline must have met the strict definition for a clinical practice guideline as set forth by the National Institute of Health and the Institute of Medicine, meaning they were informed by a systematic review of evidence and intended to direct patient care and physician decisions. Guidelines were excluded if they were identified as consensus statements, position statements, reporting standards, and training standards or guidelines. After exclusion criteria were applied, the two researchers scored each of the remaining clinical practice guidelines (CPGs) using a prespecified abstraction Google form that reflected the RIGHT statement checklist (22 criteria; 35 items inclusive of subset questions). Each item on the abstraction form consisted of a “yes/no” option; each item on the RIGHT checklist was recorded as “yes” if it was included in the guideline and “no” if it was not. Each checklist item was weighed equally. Partial adherence to checklist items was recorded as “no.” Data were extracted into Microsoft Excel (Microsoft Corporation) for statistical analysis.

Results

The initial search results yielded 129 CPGs in the following areas: 13 of the guidelines were in the field of interventional oncology; 16 in neurovascular disorders; five in nonvascular interventions; four in pediatrics; 25 in peripheral, arterial, and aortic disease; one in cardiac; one in portal and mesenteric vascular disease; 37 in practice development and safety; three in spine and musculoskeletal disorders; 14 in venous disease; five in renal failure/hemodialysis; and five in women’s health. Of the 46 guidelines deemed eligible for evaluation by the RIGHT checklist, 12 of the checklist items showed less than 25% adherence and 13 showed more than 75% adherence. Of 35 individual RIGHT statement checklist items, adherence was found for a mean (SD) of 22.9 items (16.3). The median number of items with adherence was 21 (interquartile range, 7.5–38).

Conclusion

The quality of reporting in interventional radiology guidelines is lacking in several key areas, including whether patient preferences were considered, whether costs and resources were considered, the strength of the recommendations, and the certainty of the body of evidence. Poor adherence to the RIGHT statement checklist in these guidelines reveals many areas for improvement in guideline reporting.

Radiation Dose of Patients in Fluoroscopically Guided Interventions: an Update

The benefits of fluoroscopically guided interventional procedures are significant and have established new standards in the clinical management of many diseases. Despite the benefits, it is known that they come with known risks, such as the exposure to ionizing radiation. To minimize such risks, it is crucial that the health professionals involved in the procedures have a common understanding of the concepts related to radiation protection, such as dose descriptors, diagnostic reference levels and typical dose values. An update about these concepts will be presented with the objective to raise awareness amongst health professionals and contribute to the increase in knowledge, skills and competences in radiation protection in fluoroscopically guided interventional procedures.

Acing the Joint Commission Regulatory Visit: Running an Effective and Compliant Safety Program

Ensuring the safety of patients and staff is a core effort of all health care organizations. Many regulatory agencies, from The Joint Commission to the Occupational Safety and Health Administration, provide policies and guidelines, with relevant metrics to be achieved. Data on safety can be obtained through a variety of mechanisms, including gemba walks, team discussion during safety huddles, audits, and individual employee entries in safety reporting systems. Data can be organized on a scorecard that provides an at-a-glance view of progress and early warning signs of practice drift. In this article, relevant policies are outlined, and instruction on how to achieve compliance with national patient safety goals and regulations that ensure staff safety and Joint Commission ever-readiness are described. Additional critical components of a safety program, such as department commitment, a just culture, and human factors engineering, are discussed. ^©RSNA, 2018.

Process based quality improvement using a continuous renal replacement therapy dashboard

BACKGROUND

The prevalence of continuous renal replacement therapy (CRRT) utilization in critically ill patients with acute kidney is increasing. In comparison to published and on-going trials attempting to answer questions surrounding the optimal timing of CRRT initiation, anticoagulation, and modality, a paucity of literature describes the quality of the therapy delivered.

METHODS

We conducted a single-center process improvement project to determine if a methodology to assess the quality of CRRT delivery could lead to improvement in CRRT delivery outcomes. We developed three broad categories of objective CRRT metrics to assess longitudinally, enabling creation of a CRRT Dashboard. Following the objective categories of "filter", "prescription", and "fluid balance" over time allowed us to perform quarterly analyses, target provider based CRRT education, and address variation from our standard of care. From 2012 to 2017, 184 critically ill patients received CRRT.

RESULTS

We report a mean filter life of 56 + 28.4 h, a 60-h filter life of 62%, and unplanned filter changes of 15%. Compared to a minimum target prescription of 2000 ml/1.73 m2/hour, we report the mean prescribed dose (2300 ml/1.73 m2/hour) and the rate of patients receiving at least the minimum prescription (98%). Finally, using a 10% deviation in the acceptable range of desired daily patient fluid balance, we report 83% CRRT patient days achieving an acceptable stipulated fluid goal.

CONCLUSION

We report the implementation of a quality dashboard and adopting quality improvement strategies provided a platform for measuring adherence to our institutional standards and the delivery of CRRT, specifically on the process of the care.

Standards of anesthesiology practice during neuroradiological interventions

Interventional radiology is a rapidly growing discipline with an expanding variety of indications and techniques in pediatric and adult patients. Accordingly, the number of procedures during which monitoring either under sedation or under general anesthesia is needed is increasing. In order to ensure high-quality care as well as patient comfort and safety, implementation of anes-thesiology practice guidelines in line with institutional radiology practice guidelines is paramount [1]. However, practice guidelines are no substitute for lack of communi-cation between specialties. Interdisciplinary indications within neurosciences call for efficient co-operation among radiology, neurology, neurosurgery, vascular surgery, anesthesiology and intensive care. Anesthesia team and intensive care personnel should be informed early and be involved in coordinated planning so that optimal results can be achieved under minimized risks and pre-arranged complication management.

Building a Culture of Continuous Quality Improvement in an Academic Radiology Department

As we enter a new era of health care in the United States, radiologists must be adequately prepared to prove, and continually improve, our value to our customers. This goal can be achieved in large part by providing high-quality services. Although quality efforts on the national and international levels provide a framework for improving radiologic quality, some of the greatest opportunities for quality improvement can be found at the departmental level, through the implementation of total quality management programs. Establishing such a program requires not only strong leadership and employee engagement, but also a firm understanding of the multiple total quality management tools and continuous quality improvement strategies available. In this article, we discuss key tools and strategies required to build a culture of continuous quality improvement in an academic department, based on our experience.

Improving Procedure Start Times and Decreasing Delays in Interventional Radiology: A Department's Quality Improvement Initiative

RATIONALE AND OBJECTIVES

To identify and reduce reasons for delays in procedure start times, particularly the first cases of the day, within the interventional radiology (IR) divisions of the Department of Radiology using principles of continuous quality improvement.

MATERIALS AND METHODS

An interdisciplinary team representative of the IR and preprocedure/postprocedure care area (PPCA) health care personnel, managers, and data analysts was formed. A standardized form was used to document both inpatient and outpatient progress through the PPCA and IR workflow in six rooms and to document reasons for delays. Data generated were used to identify key problems areas, implement improvement interventions, and monitor their effects. Project duration was 6 months.

RESULTS

The average number of on-time starts for the first case of the day increased from 23% to 56% (P value < .01). The average number of on-time, scheduled outpatients increased from 30% to 45% (P value < .01). Patient wait time to arrive at treatment room once they were ready for their procedure was reduced on average by 10 minutes (P value < .01). Patient care delay duration per 100 patients was reduced from 30.3 to 21.6 hours (29% reduction). Number of patient care delays per 100 patients was reduced from 46.6 to 40.1 (17% reduction). Top reasons for delay included waiting for consent (26% of delays duration) and laboratory tests (12%).

CONCLUSIONS

Many complex factors contribute to procedure start time delays within an IR practice. A data-driven and patient-centered, interdisciplinary team approach was effective in reducing delays in IR.

Approaching the Practice Quality Improvement Project in Interventional Radiology

An important component of maintenance of certification and quality improvement in radiology is the practice quality improvement (PQI) project. In this article, the authors describe several methodologies for initiating and completing PQI projects. Furthermore, the authors illustrate several tools that are vital in compiling, analyzing, and presenting data in an easily understandable and reproducible manner. Last, they describe two PQI projects performed in an interventional radiology division that have successfully improved the quality of care for patients. Using the DMAIC (define, measure, analyze, improve, control) quality improvement framework, interventional radiology throughput has been increased, to lessen mediport wait times from 43 to 8 days, and mediport infection rates have decreased from more than 2% to less than 0.4%.

Can assessing chronic pain outcomes data improve outcomes?

OBJECTIVE

This manuscript reviews how patient-reported outcomes data can be used to guide efforts to improve patient outcomes.

DESIGN

Review Manuscript.

SETTING

The clinical management of chronic, non-cancer pain.

SUBJECTS

Adult patients receiving treatment for chronic, non-cancer pain.

RESULTS

While there have been great advances in the science of pain and various therapeutic medications and interventions, patient outcomes are variable. This manuscript reviews how outcomes data can be used to guide efforts to improve patient outcomes.

CONCLUSIONS

Patient outcomes can be improved with standardization of the process of patient care, as well as through other quality improvement efforts. The cornerstone to any effort to improve patient outcomes starts with the integration of valid outcomes data collection into ongoing patient care. Outcome measurement tools should provide information on several key domains, yet the process of data collection should not pose a significant burden on either the patient or health care team. Efforts to improve patient outcomes are ongoing, and should be a high priority for every health care team.

Quality improvement in interventional radiology: an opportunity to demonstrate value and improve patient-centered care

The changing healthcare environment offers an opportunity for interventional radiology (IR) to showcase its value-specifically, to demonstrate that IR often offers the better, safer, faster, and less expensive treatment option for various clinical scenarios. The best way to demonstrate the value of IR now and to maintain this value in the future is through implementation of patient-centered care built on standardized care delivery, continuous quality improvement, and effective team dynamics.

Quality assurance and assessment in pain management

Relief from pain is itself a marker of high-quality medical care. Quality assurance in the case of pain management could simply mean successful elimination of pain. Because the means of controlling pain are imperfect, it is essential to consider whether pain interventions actually achieve the primary goal of pain relief and also whether they are safe, cost-effective, and even capable of producing secondary benefits such as early recovery from surgery. Quality assurance and assessment in pain management therefore becomes a complex undertaking that must incorporate into its processes the often-conflicting goals of comfort versus safety versus patients' rights.