CHHS16/061

Canberra Hospital and Health ServicesClinical ProcedureInterventional Radiology (Angiography)Contents

Contents....................................................................................................................................1Purpose ....................................................................................................................................3Alerts ....................................................................................................................................3Scope ....................................................................................................................................3Section 1 – Booking Process......................................................................................................3

1.1. Referral Source...........................................................................................................31.2. In-patients, Emergency and Other Hospital Patients..................................................31.3. Out-patients...............................................................................................................4

Section 2 – Pre-Procedure for outpatients only........................................................................52.1. Pre Admission Clinic...................................................................................................5

Section 3 – Day of Procedure....................................................................................................53.1. Inpatients....................................................................................................................53.1.1. Ward based Inpatients:...........................................................................................53.1.2. Day of Surgery Admission (DOSA)...........................................................................63.2. Out Patients................................................................................................................63.2.1. Day Cases................................................................................................................63.3. In Medical Imaging Day ward or Interventional Radiology Suite................................6

Section 4 – In the Interventional Radiology Suite.....................................................................7Section 5 – Procedures..............................................................................................................8

5.1. Procedures Performed in the Interventional Suite.....................................................85.2. Equipment..................................................................................................................95.3. Angiography Radiographer.........................................................................................9

Section 6 – Post Procedure.......................................................................................................9Section 7 – Discharge..............................................................................................................10

7.1. Inpatients:................................................................................................................ 117.2. Out-patient:..............................................................................................................117.2.1. Day care:...............................................................................................................117.2.2. Day of Surgery Admission (DOSA):........................................................................11

Implementation...................................................................................................................... 11Related Policies, Procedures, Guidelines and Legislation.......................................................11

Policies................................................................................................................................ 11Guidelines........................................................................................................................... 12Legislation........................................................................................................................... 12

Definition of Terms................................................................................................................. 12Search Terms.......................................................................................................................... 12Attachments............................................................................................................................12

Attachment A: Medical Imaging Angiography Record #65604...........................................14

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Attachment B: Paper Referral F00085(0902)51163............................................................18Attachment C: Medical Imaging Pre Interventional Checklist.............................................20Attachment D: Radiology Preparation Orders and Check List #60370................................21

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Purpose

The purpose of this procedure is to describe the processes and steps required to manage patient care and ensure patient safety while undergoing Interventional Radiology procedures in the Canberra Hospital Medical Imaging Angiography Suite.

Scope

Alerts

Strict adherence to Lead Shielding Personal Protective Equipment (PPE) should be maintained, in accordance with the CHHS Radiation Management policy.Ensure adherence to the CHHS Patient Identification and Procedure Matching Procedure and the CHHS Clinical Handover policy at all times.

Scope

This procedure applies to the following: Interventional Radiologist, Fellow & Registrar Interventional Nursing Staff trained in angiography procedures Interventional Radiographers trained in angiography procedures Interventional students under supervision in training for angiography procedures.

Section 1 – Booking Process

1.1. Referral SourceReferrals may be accepted from: Specialist/ Consultant Physician/ Registrar General Practitioners All requests are reviewed by Interventional Radiologist for clinical history to assist in the

planning of procedure. Metformin and warfarin are to be discussed with and ceased at the request of the Interventional Radiologist if required

Radiologist or treating team will inform the patient.

1.2. In-patients, Emergency and Other Hospital Patients Once a referral is received by Interventional Radiology, and prior to scheduling an

appointment, a clinical discussion with the referring treating team and an Interventional Radiologist, registrar or fellow should occur to ensure:o the appropriateness of the procedure/exam, and o to establish the nature, purpose and urgency of the proposed procedure.

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Once the decision is made to go ahead with the procedure the Interventional Registrar/Radiologist and/or CNC triages the request and will action as follows:o Urgent Procedures- Referring clinician must discuss with radiology

registrar/radiologist who will liaise with radiography/nursing/administrative staff to arrange the procedure to be performed.

o After hours- The referring clinician will contact the Interventional Radiologist on Call via the Canberra Hospital switchboard.

o Routine Procedures- The CNC will liaise with administrative staff to schedule the procedure.

Radiography/nursing/administrative staff will contact the ward and inform the nursing staff of the patient’s appointment.

The referring clinician will then enter the referral electronically into Radiology Information System (RIS) or submits a paper referral (see Attachment B) to the Angiography Bookings Office accompanied by a completed Medical Imaging Pre Interventional Checklist (Attachment C).

Paper referrals are entered and scanned into the Radiology Information System (RIS) by the Interventional Radiology administrative staff on receipt in the department.

Radiology Preparation Orders and Check List (Attachment D) are to be partially completed by the Angiography ward clerk with relevant information in preparation for the patient’s booking. The form will then be taken to the ward with the remainder of the form being completed by the ward nurse prior to the patient being transferred to the Angiography Suite.

1.3. Out-patients The Outpatient referral should be preceded by a clinical discussion between the

Interventional Radiologist and referring clinician, Out-patients receive a proforma letter and pathology request by mail, which is generated from the CNC booking clerk. This includes those patients who are a Day of Surgery Admission (DOSA).

The referring clinician enters the referral electronically on RIS or submits a paper referral to the Angiography Bookings Office accompanied by a Pre Interventional Checklist. Paper referrals are entered and scanned into the RIS on receipt at the Interventional Radiology Department.

Ensure the following;o Identify Clinical Indicators for the serviceo clearly identify the referring doctor’s nameo document relevant information such as co-morbidities- as per the Medical Imaging

Angiography Record attachedo Interventional Registrar/ Radiologist +/- CNC triages on receipt of the request while

indicating the following: If the procedure is deemed inappropriate on the basis of clinical information

provided, the registrar or radiologist will contact the referring doctor to discuss an alternative or cancellation. The referring doctor is then expected to contact the patient to advise of the change/ cancellation.

In the event of a patient not attending their appointment the patient will be phoned and the appointment rescheduled. If the patient does not attend for the second appointment

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a letter is sent to the referring doctor informing them that the patient has not attended for the requested procedure and the referral is cancelled from the RIS.

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Section 2 – Pre-Procedure for outpatients only

2.1. Pre Admission Clinic On arrival at preadmission clinic the patient will have:

o The Medical Imaging Angiography Record (Attachment A) commencedo bloods takeno ECG/ Vital signs performedo a consult by the Vascular teamo discussion around fasting requirements and medicationso information given regarding Day of Admission procedure.

Patient assessment for Nurse Sedation includes:o Prior illnesses and conditions (refer to indications and exclusion criteria as stated on

online request form)o medication historyo medication allergies (recorded on Medication Chart)o relevant pathology results for the procedure and patient condition e.g. platelet count

prior to lumbar punctureo previous sedation experiences and medications usedo accurate weight (recorded on Medication Chart)

Adequate preparation and education of the patient (and /or carer) should be provided An anaesthetist consult is required if the patient:

o is booked for a General Anaesthetic oro has sleep apnoea (airway issues) or o has had a previous need for General Anaesthesia o is a DOSA patient with multiple co morbiditieso at the recommendation from previous radiologist request o or at the request of the treating team.

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Section 3 – Day of Procedure

3.1. Inpatients3.1.1. Ward based Inpatients: Patient is transferred from ward to Medical Imaging Day ward with or without nurse

escort depending on the patient needs such as;o patient co-morbiditieso attachments (IV fluids/ medications)

Clinical Handover from ward nurse escort to Medical Imaging Day ward nurse Consent is performed pre-procedurally by Interventional Radiologist

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Pre-interventional checklist to be completed by ward staff

3.1.2. Day of Surgery Admission (DOSA)Patients who will require an overnight stay in a ward will present at main admission in the hospital foyer at 7:30am and be escorted to the Medical Imaging Day ward. Following arrival at Medical Imaging Day ward patients will: Change into theatre gown have a cannula inserted have site prepared by ward staff which includes shaving the groin or neck as required have bloods checked and recorded in notes have medical admission completed by treating team have a nursing admission documented on the Angiography Record #65604 (Attachment

A) have the electronic patient safety system “STOP/GO” commenced with information such

as cannulation, blood results, diabetes status and allergies documented. wait for transfer to Interventional Radiology suite in bed have a written consent completed and explained by Interventional Radiology Registrar/

Radiologist.

3.2. Out Patients3.2.1. Day CasesPatients who are expected to be discharged home at end of the day will present to Medical Imaging Admission at 8:00am and be escorted to the Medical Imaging Day ward. On arrival at the Medical Imaging Day ward patients will: change into theatre gown have a cannula inserted have site prepared by shaving the groin or neck as per entry point have bloods checked and recorded in notes have a nursing admission documented on the Angiography Record #65604 (Attachment

A) have the electronic patient safety system ‘STOP/GO’ is commenced with information

such as cannulation, blood results, diabetes status and allergies. wait for transfer to Interventional Radiology suite in bed have a written consent completed and explained by Interventional Radiology Registrar/

Radiologist.

3.3. In Medical Imaging Day ward or Interventional Radiology Suite Medical Imaging Angiography Record #65604 (Attachment A) continues from ‘Day of

Procedure’ Baseline Modified Early Warning System (MEWS) and neurovascular observations are

attended to and recorded on the patients MEWs chart and Neurovascular Observation Chart #60320. Confirm patency of cannula in Medical Imaging Day ward by nursing staff.

The electronic patient safety system ‘STOP/GO’ is commenced with information such as cannulation, blood results, diabetes status and allergies. Started in Day ward and completed in Angiography

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Patient is transferred to the Interventional Radiology Suite and a handover is given to Interventional staff by Medical Imaging Day ward staff including;o Utilising the consumer record to cross-check information, using the three unique

identifiers as per CHHS Patient Identification and Procedure Matching Policy;o Documentation of all important findings or changes of condition/care, including

reference to medications, falls and pressure injury risk and risk of deterioration; Ensure, where possible, that parents/ carers are included in handover discussions Interventional Radiologist gains written informed consent prior to procedure Team Time

Out performed. Inpatient/ Out patient has pre intervention check completed, (Attachment C) and

Medical Imaging Angiography Record #65604 (Attachment A). Any other co-morbidities relating to the particular patient. Other relevant information

such as enduring power of attorney (EPOA) or Not For Resus (NFR) or Guardianship Orders

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Section 4 – In the Interventional Radiology Suite

Theatre attire is required by all staff in the Angiography Room. Once the patient arrives in Interventional Radiology unit a ‘TIMEOUT’ is carried out by

the Radiographer, Radiologist and Registered Nurse to ensure correct patient, correct site and correct procedure as per CHHS Patient Identification and Procedure Matching Procedure.

Select patient on RIS & conduct Time Out ID MOMENT in the procedure room with the patient present and immediately before commencing the procedure, the senior clinician conducts a ‘time out’ as a single operator or leads the team in a ‘time out’ and verbally confirms: o Correct patient is presento Correct procedure to be performedo Correct side/site is identified and markedo Consent is cross-checked with proposed procedure and where appropriate for the

procedure: Correct patient details are on the imaging device Correct previous images are displayed Implant/equipment/medication is available and correct.

Patient is transferred across onto the Interventional Radiology table, utilising transfer equipment and extra staff to assist

Observations of pulse rate, respiratory rate, oxygen saturation and blood pressure monitored at least every 5-10 minutes during the procedure

Sedation score rating documented on observation chart every 5 minutes Sedation Nurse must be deemed competent through the Medical Imaging Sedation

Nurse Self Directed Learning Package (SDLP) and competency test. Interventional Radiologist/registrar prescribe sedation pre operatively unless in urgent

cases.

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When the Interventional Radiologist/ Fellow/ Registrar is unable to provide a written order prior to the procedure, the sedation nurse can obtain a verbal order ...

When the Interventional Radiologist/ Fellow/ Registrar are unable to provide medication order for sedation, the sedation nurse follows CHHS15/086 (Medication Handling Policy) subsection 2.5.6 (Verbal and Telephone Medication Orders) where verbal order is taken from Radiologist/ Fellow and scribes dosages and time intervals along with observations

Interventional Radiologist signs order at end of procedure Scrub Nurse will scrub in and prepare Interventional Radiology trolley following the

aseptic non touch technique CHHS Aseptic Non Touch Technique and Australian College of Operating Room Nurses (ACORN) standards.

All scrub staff are required to completeo Aseptic Technique trainingo Scrubbing Gowning & Gloving Self Directed Learning Package and be assess as

competent Patient prepared and draped as per ACORN standards for interventional surgical

procedure.

Alert: Chemotherapy precautions are to be carried out by staff, if the patient is undertaking or has had recent chemotherapy.

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Section 5 – Procedures

5.1. Procedures Performed in the Interventional Suite

Adrenal Vein Sampling IVC Filter InsertionAngiogram Pelvis IVC Filter RemovalAngiogram Abdomen Nephrostomy InsertionAngiogram Aorta/Femoral Angiogram Nephrostomy ExchangeAngiogram Head & Neck Nephrostomy Removal-JJ in SituAngiogram Lower Limb NJ Tube ChangeAngiogram Renal NJ Tube InsertionAngiogram Thorax Ovarian VenogramAngiogram Upper Limb Petrosal venous samplingPercutaneous Transluminal Angioplasty (PTA)

PICC Line Insertion

Balloon placement/ embolisation for placenta accreta

Portacath insertion

Biliary Drain (Insertion/ exchange/ removal) Radiofrequency AblationBiliary Metal Stent Insertion Remove Foreign BodyBiopsy Renal Calculus RemovalPercutaneous Transhepatic Cholangiogram (PTC) plus Drain Insertion

Renal Renins Sampling

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Embolisation (Neuro) Trans Arterial Chemo Embolisation (TACE)Embolectomy Testicular VenogramEmbolisation varicocele ThrombolysisEmbolisation varicose veins/ pelvic congestion

Transinterjugular Intrahepatic portosystemic Shunt (TIPS)

Embolisation(General) Tunnelled Line - DialysisERCP in Angio Suite Tunnelled Line - NON DialysisEVAR abdominal aortic aneurysm Ureteric JJ Stent Insertion/ RemovalEVAR fenestrated Uterine VenogramEVAR thoracic aortic aneurysm Venogram- AbdoFistula angioplasty Venogram- Lower LimbFistulagram/ Loopogram Venogram- PelvicGastrostomy- Change Venogram- ThoraxGastrostomy- Check Venogram- Upper LimbGastrostomy- Insert Computerised Tomography Interventional

Hysterosalpingogram 2D Perfusion

Consultation (Initial/ Followup) Thrombolysis (Neuro)Vascular Stent Insertion

5.2. Equipment Refer to Procedure setup card & Radiologists preference card for interventional

procedures, stored electronically in the Interventional Radiology Unit preparation room. Equipment set up for procedures listed in Section 5.1 will be according to each

Interventional Radiologist’s preference.

5.3. Angiography Radiographer Responsible for safe and effective operation of imaging equipment and imaging

applications. This encompasses:o Radiation Safety and Protection (ALARA Principle)o Radiation Safety Management Plano Image acquisition and post Processingo Data tracking and Procedure Codingo Audit Data Collection.

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Section 6 – Post Procedure

The Registered Nurse will complete the ‘Interventional Radiology’ procedure sticker in the patient’s notes. Ensure the Radiologist signs the written and/ or verbal medication orders and documents post-procedural orders.

Patient is transferred to their bed on a pat slide and escorted by either the Interventional Radiology scrub or sedation nurse to Medical Imaging Day ward

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Handover from Angiography nurse to Medical Imaging Day ward staff Following Medical Imaging Angiography Record #65604 (Attachment A) and continuing

from “Post Procedural Observations”, Interventional Radiology Record should be completed and placed in the patient’s clinical record

The arterial puncture site is also examined as part of the handover for any signs of swelling or bruising following below criteriao If manual compression applied – 15 minutely for 2 hours then 30 minutely for 4 hrs

unless otherwise instructed by the radiologisto If a Closure Device is used – 15 minutely for 1 hour then 30 minutely for 1 hour

unless otherwise instructed by the radiologist.

ALERT: Post Procedure Escalation of Arterial Bleeds

Only Direct Digital Pressure (DDP) is to be used for vascular patients when applying pressure to puncture sites, (DO NOT USE SANDBAGS OR FLUID BAGS)

Arterial puncture sites can, and do bleed - EARLY INTERVENTION AND DOCUMENTATION IS VITAL TO ACHIEVE POSITIVE OUTCOMES

If there is no response by the Vascular Team (Including Radiologist) AND/OR THE PATIENT IS DETERIORATING - continue with direct digital pressure over the puncture site >> CALL MET

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Section 7 – Discharge

Following the Medical Imaging Angiography Record #65604, the following ‘Discharge Criteria’ will be completed: (Attachment A): Post procedure education No swelling or bleeding at procedural puncture site observed Puncture site observations are charted in patient notes Pain Score <4 IV cannula will be removed if patient is going home Patient given post procedural care instruction Angioseal information record given to the patient Informed verbally about care of puncture site. Patient has follow up appointment, if

necessary Ensure all patient belongings including X-ray and own medications are with the patient Transferred to ward time indicated In-patients require ward escort to go back to ward Patient signature on discharge with date and time On discharge, ensure patient is escorted with a carer.

7.1. Inpatients: Ward patients are monitored until vital signs have stabilised and are then transferred

back to the ward 30 minutes post procedure,

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Transport is organised with ward services and contact is made with destination ward nurse prior to transport

Patient escorted by Medical Imaging nurse back to ward, where clinical handover is conducted

7.2. Out-patient:7.2.1. Day care: Patients are monitored until vital signs have stabilised in Medical Imaging Day ward or

until discharged at end of day as per discharge instruction Patient discharged from Medical Imaging Day ward utilising above discharge criteria

7.2.2. Day of Surgery Admission (DOSA): Patients are monitored until vital signs have stabilised in Medical Imaging Day ward and

are then transferred to the destination ward as per bed management arrangements. Transport is organised through ward services for transfer to destination ward Ward is notified that patient escort is required Patient transferred to destination ward and clinical handover given If patient has brought in own medications, ensure all medications are transferred with

the patient.

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Implementation

Included in New Staff Orientation Manual Standing item at Angiography Meeting reviewing document

Related Policies, Procedures, Guidelines and Legislation

PoliciesRadiation Safety Management Plan (23/01/2015) 7.2, p 22 of 36Non Critical Patients CHHS14/039Procedural Sedation SOP TCH07:005Escorting Patients Policy TCH10:008Clinical Handover Policy CHHS15/069 Healthcare Associated Infections CHHS15/072, subsection 2.9 “Code of Dress or Attire in Restricted/Semi restricted Procedure Areas” Patient Identification and Procedure Matching CHHS14/052 Central Venous Access Device (CVAD) Management – Children, Adolescents and Adults (NOT Neonates) CHHS13/572Aseptic Non Touch Technique CHHS14/011Personal Protective Equipment SOP Document Number CHHS12/251Clinical Handover, CHHS15/069

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Guidelines Radiation Safety Management Plan November 2014Australian College of Operation Room Nurses (ACORN), 2014-2015Australian Radiation Protection and Nuclear Safety Agency (ARPNSA), publication No. 14.1, 2008The Royal Australian and New Zealand College of Radiologists (RANZCR) Standards of Practice, 2007

LegislationRadiation Protection Act 2006 (A2006-33)

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Definition of Terms

As Low As Reasonably Achievable (ALARA), is an acronym for an important principle in exposure to radiation and other occupational health risks. The aim is to minimize the risk of radioactive exposure or other hazard while keeping in mind that some exposure may be acceptable in order to further the task at hand.

ACORN: The ACORN standards provide a minimum standard of practice for perioperative nurses, and requirements for visitors and healthcare facilities

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Search Terms

Angiography Suite, Angiogram, Angioplasty, Embolisation for placenta accrete, Biliary Calculus Removal, Biliary Drain Change, Biliary Metal Stent, Cholangiogram EmbolisationEmbolisation varicocele, Embolisation, ERCP, EVAR, Fistula angioplasty, Fistulagram, Gastrostomy-Hysterosalpingogram, Interventional Radiology, IVC Filter, Lumbar Puncture – Nephrostomy, NJ Tube Change, NJ Tube Insertion, Ovarian Venogram, Petrosal venous sampling, PICC Line Insertion, Portacath insertion, PTC & Drain Insertion, Radiofrequency Ablation, Remove Foreign Body, Renal Calculus Removal, Renal Renins Sampling, SialogramTACE-chemoembolisation, Testicular Venogram, Thrombolysis dialysis fistula, TIPS-ortocaval shunt, Tunnelled Line, Ureteric JJ Stent Insertion, Uterine Venogram, Venogram, Vertebroplasty Arterial Bleeds, Radiation Safety Management Plan, e-Orders, ALARA Principle, Did Not Attend (DNA)

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Attachments

Attachment A: Medical Imaging Angiography Record #65604Attachment B: Paper Referral F00085(0902)51163Attachment C: Medical Imaging Pre Interventional Checklist

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Attachment D: Radiology Preparation Orders and Check List #60370

Disclaimer: This document has been developed by ACT Health, <Name of Division/ Branch/Unit> specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Date Amended Section Amended Approved ByEg: 17 August 2014 Section 1 ED/CHHSPC Chair

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Attachment A: Medical Imaging Angiography Record #65604

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Attachment B: Paper Referral F00085(0902)51163

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Attachment C: Medical Imaging Pre Interventional Checklist

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Attachment D: Radiology Preparation Orders and Check List #60370

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