Nuclear technologists need to lead facility accreditation efforts
With the ever increasing scrutiny on image quality and the inevitable need for all U.S. facilities to be nationally accredited, it is incumbent upon nuclear medicine technologists to provide the highest quality studies to its providers for purposes of certification and reimbursement, according to a presentation Sept. 12 at the American Society of Nuclear Cardiology (ASNC) conference.

“Increasingly, more and more insurance companies are requiring accreditation from either ICANL [Intersocietal Commission for the Accreditation of Nuclear Medicine Laboratories] or ACR [American College of Radiology] to receive reimbursements,” Timothy L. Dunn BS, CNMT, technical director of nuclear cardiology at the Maine Cardiology Associates in South Portland, Maine, said during his ASNC presentation.

This year, Congress passed the Patients and Providers Act on July 9. The bill requires that by 2012, providers of advanced diagnostic imaging services, including nuclear medicine, MR, CT and PET, must obtain accreditation as a condition for reimbursement. In 2012, the ICANL will become a mandated accreditation.

In addition, the legislation established a two-year voluntary program to collect data regarding physician compliance with appropriateness criteria to determine the appropriateness of advanced diagnostic imaging services furnished to Medicare beneficiaries.

“By 2012, if you don’t have it, you’re not getting paid, and if you’re not getting paid, you’re out of a job,” Dunn clarified. “We will all need to be accredited in the very near future in order to continue to provide patient services.”

He said that the means of accreditation is through adherence to ASNC and ICANL guidelines for acquisition and processing.

He noted that the acquisition varies depending upon protocols whether it is rest/stress, stress/rest, two-day protocol or stress only protocols. While two-day protocols are not the most convenient in office settings, they provide the best images, according to Dunn. He said that it is “important to remember that when doing one-day protocols that you have a 3:1 ratio of high dose to low dose to ensure proper counting statistics and ensure that you have sufficient counts on high-dose images to mask over your low dose images.”

To reduce patient motion, Dunn said that it is important that the patient is as relaxed as possible before beginning imaging, whether it is post stress or post rest, keeping the heart rate at baseline.

He cautioned that gating patients with irregular heart rates, especially patients with atrial fibrillation or frequent ectopy, can lead to an inaccurate determination of ejection fraction (EF) and wall motion due to counts being placed in wrong bins nd significant variation of R-R interval, as well as greatly increased imaging time that can lead to increased patient motion.

He also stressed the need to be “careful with some systems gating patients with pacemakers as some of these systems will detect the pacer spike, which will lead to an overestimated HR [heart rate] and counts being placed in wrong bins.” Dunn said that if possible, disable the pacer before imaging.
In order to avoid rescans, Dunn reviewed a few methods to eliminate artifacts. “It is essential that you review each set of images before you release the patient (to ensure that you don’t have excessive motion, artifact, bowel interference corruption of data, etc.).”

“I know that we all work in busy offices and hospitals, so reprocessing the patient can be tremendously time consuming,” Dunn noted. “If you have poor image quality for any reason it is much easier to immediately rescan patient rather much easier than try to get patient back later.”

He encouraged nuclear technologies that if possible, completely process and review study, before patient leaves the department. He added that the facility will only get reimbursed for one set of images, even if two-day imaging is performed.

For processing considerations, Dunn said that it is essential that the technologist and reading physician collaborate to create specific defaults for processing for that site, which usually requires customizing default settings to physician preferences.

“You must create settings for all of your imaging protocols, such as one-day, two-day or dual isotopes. Once these settings have been created, it is essential that the technologist does not change them—such as changing filters or frequency cutoffs—unless under the direct supervision of reading physician,” Dunn stressed.

He stressed this importance because “by changing the settings of your processing parameters, you may inadvertently cover a defect, making an image too smooth, or you may create a defect that doesn’t that doesn’t really exist, making the image too rough.”

He also advised technologists to review all raw data—motion, artifacts, quality of images—before processing, adding that it is particularly important to have both rest and stress image aligned the same, so they can be evenly and equally compared.

Dunn concluded that while following these guidelines will not only allow for certification and reimbursement, it will provide the best quality of care and results for the patients.