COLLINS: Was there a clinical experience that sparked your interest in radiation safety or patient safety in IR?
DUNCAN: This project grew out of our interest in procedural simulation as a training tool. As we worked to improve training, we recognized a need for objective measures of performance. Use of simulated radiation was one of the metrics and we began to realize that we need to better understand what factors drive radiation use in actual procedures.
COLLINS: Can you summarize the broad objectives of your Funding Source Development Grant funded by SIR Foundation in 2011?
DUNCAN: The development grant had two aims: 1) to develop a protocol for standardized collection of radiation metrics for fluoroscopy procedures and 2) to develop a protocol for aggregation and analysis of that data. The protocol for standardized data collection has become the DICOM radiation dose structured reports (RDSRs). In 2011, equipment that was capable of generating structured reports was just being developed and we created a workflow that allowed us to incorporate it. Data aggregation and analysis has been simplified dramatically by the increasing availability of dose monitoring programs. One of the key problems we encountered was ascertaining the complexity of IR procedures. We found that procedures could be classified according to their string of current procedural terminology (CPT) codes, which enabled us to better match the radiation dose data with procedural complexity.
COLLINS: What are the components of an effective patient safety program focusing on radiation dose in IR?
DUNCAN: It comes down to three components: 1) collect data, 2) analyze data in an ongoing fashion and 3) make and test data-driven predictions regarding dose and procedural time.
COLLINS: What are the most effective strategies to improve patient safety in regards to radiation dose, particularly in IR?
DUNCAN: Reviewing and revising your default protocols. Image Gently and Image Wisely have nicely demonstrated how reviewing and revising CT protocols leads to marked improvements. The same ideas can be applied to the protocols used in fluoroscopic procedures. Largely because of the pediatric aspect of our practice and the timing of a new room installation in 2008, we built child-sized (Image Gently) protocols. We started seeing that the larger children (i.e., teenagers) were receiving lower doses than did small adults undergoing identical procedures while maintaining image quality adequate for procedural guidance. We then translated these protocols over to our adult hospital, designing low-dose adult protocols and making them the
default setting on our equipment. Operators often found image quality with the lower-dose protocols adequate for guidance. IRs can work with their radiology technologists to adjust the imaging technique when necessary for procedural guidance.
COLLINS: What barriers have you encountered in establishing a culture of radiation safety in IR?
DUNCAN: It’s common to hear issues like “I can’t see what I need to” or “we are worried about workflow.” While fluoroscopy time for our average case has remained stable, suggesting that the lower image quality did not impair procedural guidance, we have seen a sustained 50 percent decrease in reference point air kerma. The good news is that everyone—all operators, nurses and technologists— wants to see his or her personal radiation dose decline.
COLLINS: What is the most important patient safety issue facing interventional radiology?
DUNCAN: I would go back to managing expectations. I’ve definitely had cases where we told the patient and their family that we are performing a complex procedure habitus there is a chance that we will require a substantial radiation dose, which could result in a skin injury. As part of the discussion, I inform patients that we will work to minimize this risk. We can do a better job of telling patients that they are at the limits of what we can help with. Alternatively, we can tell patients that their procedure is routine and they should expect it to last 30±2 minutes. Everyone desires a successful procedure but I find that they appreciate a discussion of our strategy for optimizing the balance between the risks and benefits.
COLLINS: Given your expertise with simulation in IR can you comment on its potential role in improving patient safety?
DUNCAN: I would turn it around and say that prior cases are your simulation training for a subsequent case. How certain are you that tomorrow’s case will be similar to all of the cases you trained on? How do we get experience? You can study your past or make up scenarios (simulations)—either computer-driven simulators or thought experiments. Simulators do a terrific job creating all of these interesting stimuli, but you can get the same teaching watching someone perform a procedure, including reviewing video from recorded procedures. There is terrific data showing that we learn nothing from our successes; rather we learn everything from our failures. Other professions do a much better job of debriefing after difficult procedures. We essentially walk away, wipe our brow and declare “tough case” and then go to the next case. If someone has a better way of solving a difficult problem, we should have a better way of studying their technique so that we can all learn from their experience.
COLLINS: There are many facets of patient safety in a procedure-based specialty such as IR. How can we as a Society improve our awareness of patient safety issues and translate this into a culture of patient safety in clinical practice?
DUNCAN: It is the recognition that patient safety is a problem best approached by a team. It’s not only the physicians but also the technologists, nurses and manufacturers who produce the equipment because the human machine interface is huge in our equipment. Also, for patients it is the understanding that, although there are many problems we as interventional radiologists can fix, there are some that we cannot. Managing expectations and providing predictions to patients and their families about the subsequent 24–48 hours empowers them to look for signposts along their journey that may indicate that they or their loved one’s postprocedural course is not going as planned. This initiates the conversation regarding what else could be going on.
COLLINS: Lack of resources may be a limiting factor to a successful patient safety program. What strategies have you found to support these initiatives at the institutional level?
DUNCAN: You have to get the hospital involved. The proposal has got to be something that makes sense to them: What is their return on investment? Look for opportunities to demonstrate the utility of well-planned patient safety programs in the context of patient safety issues (near-misses or actual events) as they arise. Be prepared with a comprehensive plan and update the hospital administration with the small wins after the system is in place.
COLLINS: A barrier to comprehensively assessing the radiation exposure risk to patients is their history of radiation exposure and life expectancy. Have you seen or considered any solutions to this pressing issue?
DUNCAN: The first question is “can we do better within our enterprise?” It will be hard for me to collect data from an outside institution. However, what we should be able to do (and, honestly, what patients already expect us to be doing), is to be aware of imaging that happened at facilities within our institution or network. Most patients don’t have any idea of how bad our information systems are at sharing radiation dose data. However, now that there are structured reports, this should improve.
COLLINS: What do you enjoy doing when you are not performing procedures or thinking about patient safety in interventional radiology?
DUNCAN: It’s pretty nerdy—I like collecting data from my exercise sessions. I have a bunch of gadgets that collect different data streams. It’s driven by the same principle that I apply in the workplace—I am obsessed with wanting data that I can use to test improvement strategies.
