Northern California SGNA Meeting September 22, 2012

Radiation safety in the ERCP suite

Disclosure Statement Product Specialist for Core Medical Imaging Core Medical Imaging Distributor of Omega’s E-view system for ERCP studies

Radiation Safety in the ERCP suite EndoscopicRetrogradeCholangioPancreatographyFluoroscopy

Radiation Safety in the ERCP suite Radiation Safety in the ERCP suite Objectives: To discuss: Four equipment configurations Basics of x-ray Scatter radiation Minimize radiation dose

Radiation Safety in the ERCP suite Radiation Safety in the ERCP suite Today’s goal: Understand fluoroscopy to: Compliment exam Minimize radiation exposure

Radiation Safety in the ERCP suite Why are these goals important to a Nurse?

Radiation Safety in the ERCP suite Radiating the patient is part of “Patient Care!”

Radiation Safety in the ERCP suite What is Fluoroscopy? (in English)

Radiation Safety in the ERCP suite What is Fluoroscopy?  Low dose x-ray image  Taken at 30,15 or 7.5 times/sec  Displayed at 30 frames/sec

Radiation Safety in the ERCP suite 2 Radiation items you need to know: #1 Less is better #1 Less is better #2 Inverse square law

Radiation Safety in the ERCP suite 2 Radiation items you need to know: #1 Radiation - Less is better #1 Radiation - Less is better (= image quality)

Radiation Safety in the ERCP suite Radiation: the opposite of chocolate

Radiation Safety in the ERCP suite 2 Radiation items you need to know: #2 Inverse square law #2 Inverse square law

Radiation Safety in the ERCP suite Inverse square law: 2 x the distance =’s 4 x the radiation

Radiation Safety in the ERCP suite Inverse square law: 3 x the distance =’s 9 x the radiation

Radiation Safety in the ERCP suite Application of Inverse Square law Image Intensifier - close to patient as possible. X-ray tube – far away from patient as possible.

Radiation Safety in the ERCP suite EquipmentConfigurations

4 equipment configurations do 98.56% of all ERCP’s

Radiation Safety in the ERCP suite 47.07% of exams ERCP Modalities - Portable C-arm

Radiation Safety in the ERCP suite Portable C-arm Advantages:  Least cost (~$225,000)  Every hospital has 1 or 2 or 3  Tube angulation

Tube angulation Image viewed straight on Cystic Duct superimposed C-Arm angled to view Cystic Duct

Radiation Safety in the ERCP suite Portable C-arm Dis-advantages:  Image quality  Radiation dose  Slow/hard to use

Radiation Safety in the ERCP suite ERCP Modalities - Rad/Fluoro room 28.52% of exams

Radiation Safety in the ERCP suite Rad/Fluoro room Advantages:  Image quality  Radiation dose  Moderate expense ($300K - $325K) ($300K - $325K)

Radiation Safety in the ERCP suite Rad/Fluoro room Dis-advantages:  No tube angulation  Non elevating table  Patient orientation

Radiation Safety in the ERCP suite ERCP Modality - Multi Purpose room 17.24% of exams

Radiation Safety in the ERCP suite Multi Purpose room Advantages:  Image quality  Radiation dose  Tube angulation  Elevating table

Radiation Safety in the ERCP suite Multi Purpose room Dis-advantages:  Equipment cost ($550K+) ($550K+)  Complexity  Room size

Radiation Safety in the ERCP suite 2.72% of exams ERCP Modalities Dedicated designed

Radiation Safety in the ERCP suite Dedicated designed Advantages:  Image quality  Radiation dose  Tube angulation  Elevating table

Radiation Safety in the ERCP suite Dedicated designed Dis-advantages:  Cost $400K

Radiation Safety in the ERCP suite Scatter Radiation Why is it important? Why is it important?

Radiation Safety in the ERCP suite  WGO 2009  “For endoscopists and staff, the major source of x-ray exposure is scattered radiation from the patient, not the primary x- ray beam.”

Radiation Safety in the ERCP suite <1% Table top 98+% Patient <1% Image Int.

Radiation Safety in the ERCP suite Scatter Radiation How to minimize it How to minimize it

Radiation Safety in the ERCP suite Minimize Radiation Dose Lead Shielding

Radiation Safety in the ERCP suite Table drape for nurses

Radiation Safety in the ERCP suite Minimize Radiation Dose Pay attention to the fluoro dose the fluoro dose readout device readout device

Radiation Safety in the ERCP suite Minimize Radiation Dose Required in 2006 Display results

WGO Guidelines /downloads/en/pdf/guidelines/23_wgo_radi ation_protection_in_endo_suite_en.pdf

WGO Guidelines Level 1: high resource levels Level 2: average resource levels Level 3: minimum resource levels

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

Radiation Safety in the ERCP suite Summary 1) Radiation – less is better 2) Use Inverse square law 3) Proper shielding

Radiation Safety in the ERCP suite Questions?

References Slide # 10 – WGO Practice Guideline: Radiation protection in the endoscopy suite Slide # 20 – Survey conducted by Don Dockter Slide # 21 – Survey conducted by Don Dockter Slide # 25 – Survey conducted by Don Dockter Slide # 28 – Survey conducted by Don Dockter Slide # 31 – Survey conducted by Don Dockter

Radiation Safety in the ERCP suite References Slide # 36 – Mr. James Princehorn, President Omega Medical – WGO Practice Guideline: – WGO Practice Guideline: Radiation protection in the endoscopy suite Slide # 41 – 21CFR, part all diagnostic x-ray device must display Entrance Air Kerma Rate, Accumulated Air display Entrance Air Kerma Rate, Accumulated Air Kerma, and Accumulated Fluoro Time. Kerma, and Accumulated Fluoro Time. Slide # 44 – WGO Practice Guideline: Radiation protection in the endoscopy suite