RSNA: Pre-imaging checklist helps cut fluoro times for residents

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CHICAGO—Pre-procedural checklists for common fluoroscopic gastrointestinal and genitourinary imaging procedures reduce fluoroscopic times and may improve communication among a multidisciplinary team of radiologists, residents and technologists, according to a scientific poster presented Nov. 28 at the Radiological Society of North America (RSNA).

Radiation dose delivered during fluoroscopy exams is highly dependent on operator experience and familiarity with each procedure, which is especially important for first-year residents who can be “naïve to these multistep procedures,” according to the study authors. 

Michael J. DeLeo, III, MD, and colleagues from radiology department at the Hospital of the University of Pennsylvania in Philadelphia , sought to reduce radiation dose and improve team performance during fluoroscopic exams performed by first-year residents by developing pre-procedural checklists for common gastrointestinal and genitourinary fluoroscopic exams.

“Previous work demonstrated that the use of checklists can improve communication and team performance, which is important for first-year residents since they learn these procedures from a multidisciplinary team of senior radiologists and technologists,” the researchers wrote. This team had previously demonstrated that the use of targeted educational and training interventions can significantly reduce fluoroscopy times. 

Rather than use remediation to improve fluoroscopy times, in this study, they hypothesized that proactive use of pre-procedural checklists can reduce fluoroscopy times while also improving efficiency and communication.

“We measured the fluoroscopy times of the 11 first-year residents for all the procedures, and averaged those times. It seemed very high that on average double upper gastrointestinal exams were taking more than five minutes, and the retrograde and hysterosalpingography exams also were high,” DeLeo told Health Imaging.

Checklist items include goal fluoroscopy time, basic procedural steps and tips for difficult aspects of each procedure. DeLeo and colleagues compared fluoroscopy times for first-year residents before and after implementation of pre-procedural checklists using a resident database of fluoroscopy times. They identified one resident whose mean fluoroscopy times for genitourinary procedures was two standard deviations below that of his peers and used these mean times as a benchmark for resident performance. 

“The concept beyond the checklist, somewhat inspired by Atul Gawande’s book The Checklist Manifesto, is the first-year resident and the technologist can quickly discuss and check off approximately four boxes to ensure that the proper steps have been and will be taken for the procedure to be performed appropriately and quickly,” DeLeo  said. “It’s particularly important for residents who aren’t as familiar with the procedures, but the checklist also could be a helpful reminder for a seasoned radiologist.”

For hysterosalpingography, the mean fluoroscopy time decreased from 0.93 minutes before implementation of pre-procedure checklists to a mean of 0.2 minutes. Mean fluoroscopy times decreased for retrograde pyelopgraphy (from 6.71 minutes) before to 4.34 minutes after and voiding cystourethrography (from 2.41 minutes) before to 0.81 minutes after implementation of pre-procedure checklists. 

The study’s second author, Jason Neil Itri, MD, PhD, a diagnostic radiologist at the Hospital of the University of Pennsylvania, has created a fluoroscopy dashboard, called Orion, in which the residents can login and compare their fluoroscopy times to their peers. Therefore, the residents can immediately know whether they are an outlier one way or the other, DeLeo explained.

The researchers continue to collect data for other genitourinary procedures, and data collection for gastrointestinal procedures is currently underway.