Enhancing Patient Safety:Standardization of CT Contrast
Media PracticesPrerna Kahlon, BDS, MPAH, CPHQa, Kathryn McCullough, MSa,
G. Scott Gazelle, MD, MPH, PhDa,b
Large health care systems with varied hospital cultures, environments, and practices are continually challengedto provide safer and higher quality patient care. The authors describe their experience implementing uniformprocedures for computed tomographic contrast media administration and the impact that standardization ofthese practices had on patient safety at a large integrated health care system.
n radiology departments with high daily volumes ofomputed tomographic (CT) examinations, a large num-er of outpatients are injected with intravenous (IV)ontrast material. High patient volumes exacerbate thehallenge of obtaining outside laboratory results or othernformation before scanning, which therefore increaseshe possibility of IV contrast being injected into a patientho is at increased risk for an adverse reaction [1]. Theroper management of contrast requires knowledge ofatient risk [2,3]. In addition, it requires standards fordentifying, recording, and responding to those risks. Inhis way, variation in CT contrast policies and proce-ures can lead to variation in CT contrast media admin-
stration practices, resulting in decreased patient safety.he inability to track patients’ prior CT contrast reaction
nformation can lead to the reoccurrence of CT contrasteactions, leading to decreased patient satisfaction andafety, in addition to increased costs associated with man-ging the reactions [4].
In this paper, we describe our experience implement-ng uniform procedures for CT contrast media adminis-ration and the impact of the standardization of theseractices on patient safety at a large integrated health care
Department of Radiology, Partners Healthcare System, Boston, Massachu-etts.
Department of Radiology and Institute for Technology Assessment, Massa-husetts General Hospital, Boston, Massachusetts.
Corresponding author and reprints: G. Scott Gazelle, MD, MPH, PhD,01 Merrimac Street, 10th Floor, Boston, MA 02114-4724; e-mail:
ystem composed of 6 hospitals. Our systemwide CTontrast team (CCT) began this multiphase initiative in003 with the objective of enhancing patient safety byeveloping uniform policies and procedures for the use ofontrast media in computed tomography throughout theetwork.
ETHODS
he CCT began by examining existing practices usingurveys, interviews, and site visits. They collected andompared the various screening tools used at each hospi-al for identifying patients at risk for contrast reactionsefore their examinations. Information was gathered onontrast media administration guidelines, including pre-edication regimens, drug interactions, and definitions
nd classification of contrast reactions. The team thenxamined how each site was documenting contrast reac-ions and communicating information about patientsith histories of contrast reaction. From there, existingrocesses were flowcharted and failure points identified.
ESULTS
nalysis and Interpretation
ariation was observed in CT contrast policies and pro-edures. The majority of the institutions (83%) weresing screening forms to identify risk for contrast reac-ions in patients, but all of these forms were different. Noonsistent contrast media administration guidelines wereeing followed. Only 50% of the hospitals were classify-
ng contrast reactions according to the ACR’s classifica-
Kahlon et al/Standardization of CT Contrast Media Practices 563
ion. There was no centralized repository to monitor andrack rates of contrast reactions at any of the hospitals;owever, ad hoc manual reports were available whenequired.
None of the 6 hospitals’ radiology departments wereble to record CT contrast reaction information for newatients in our systemwide electronic medical recordEMR) or to successfully obtain historical informationbout CT contrast reactions from the EMR for returningatients. The inability to electronically track contrasteaction information across the system was a significantatient safety concern. It was felt that failure to achievehis objective was due to the technologists or nurses notaving access to the EMR and a lack of a well-definedrocess to both enter and view prior contrast reactionnformation in the EMR.
trategy for Change
he results of the assessment led to the formulation oftandard CT contrast policies and procedures. The CCTrst standardized CT contrast reaction definitions as per
CT study with contrast ordered via
Radiology Order Entry / RIS / Hospital
Specific CPOE
PEARInformente
EMR
Informindicaradio
report
Allergy data populated
into CT study order
Contraindication to IV / oral contrast?
1. CT without contrast2. Alternate Imaging Protocol3. Reschedule with premedication
Patient study wit
Yes
No
ig 1. Proposed process. CPOE � computerized pMR � electronic medical record; IV � intravenous
adiology information system.
he ACR’s classification for contrast reactions [5]. TheT contrast media administration policy was also stan-ardized. The team incorporated best practices from the
ndividual hospitals’ policies, along with the ACR’s CTontrast media administration policy to develop a sys-emwide standardized CT contrast media administrationolicy. The policy addressed issues such as screening andlassification of reactions, approaches for respondingo contrast media–induced nephropathy, and special clini-al circumstances, such as metformintherapy,diabetes, sickle-ell anemia, and pheochromocytoma.
Simultaneously, the CCT worked to develop a stan-ard CT contrast IV patient questionnaire and an ad-erse drug event form. The CT contrast IV patient ques-ionnaire targeted the issue of screening patients for riskor contrast reactions. It was used to screen patients’istories of allergic and idiosyncratic reactions, premed-
cation regimens, and current medications, especially these of metformin and interleukin-2 therapy. In addition,he questionnaire asked for information concerningonditions such as kidney disease, diabetes, sickle-cell
564 Journal of the American College of Radiology/Vol. 6 No. 8 August 2009
nemia, pheochromocytoma, multiple myeloma, car-iac disease, and collagen vascular diseases such as
upus. For female patients, it also included questionselated to pregnancy and breastfeeding. In this way,he CT contrast IV patient questionnaire was createds a useful resource to provide easy access to valuablenformation for assessing a patient’s risk for experienc-ng a CT contrast reaction.
The adverse drug event form was developed to facili-ate consistent and reliable documentation of reactions.f a contrast reaction occurs, the adverse drug eventorm is used to document contrast reaction infor-ation. Details on the contrast agent used are do-
umented, including the type of agent, lot number,oncentration, amount of contrast injected, time admin-stered, indication, and protocol. The type and severity ofeaction, treatment provided in the radiology depart-ent, recommendation for future studies, and commu-
ication of this information are also specified in the ad-erse drug event form. Once drafted, both the CTontrast IV patient questionnaire and the adverse drugvent form went through a rigorous review process andere presented to the forms committee at each hospital
or final approval.Concurrently, a CT contrast reaction monitoring
ashboard was created and hosted on a password-pro-ected Web site. The dashboard displays reactions byospital, contrast type, total number of injections given,
NameMRN DOB, Age, SexNameMRN DOB, Age, Sex
ig 2. Electronic medical record (EMR) screenshot. CT
otal number of reactions, and severity of reaction. Pleaseefer to the online appendix to view a sample report fromur CT contrast reaction monitoring dashboard.
With the forms and dashboard in place, the CCTonsidered how best to make the relevant informationvailable to those responsible for making decisions aboututure contrast administration. It was determined thathe information should be captured in a manner thatould be easily retrieved and used to help prevent possibleuture reactions in patients. It was concluded that thiseeded to be an automated process (see Figure 1).In November 2005, the CCT started to work with the
nformation technology department to get access to theMR by outlining a standard process for documenting
eactions and future retrieval of the same. Beginning inugust 2006, the radiology departments received access
o the EMR, which enabled the technologists and nurseso enter and check systemwide patient CT contrast reac-ion information (see Figure 2). A separate field wasreated in the allergy repository section of the EMR toocument new or prior contrast reactions. Various signsnd symptoms could also be checked off in this field, andree text could be entered in the comments section (seeigure 3). Technologists and nurses were trained on howo use this new field in the EMR. Workflow changes werehen made in each radiology department to incorporatehe new process. This step was especially valuable when aatient went from one hospital in the system to another;
To add a new CT contrast reaction, select “Add New,”which will take you to the allergy repository section of the EMR
From the Allergies Field, you can view the list of all allergies, including all contrast allergies
Double click on an allergy to read comments about the reaction
To add a new CT contrast reaction, select “Add New,”which will take you to the allergy repository section of the EMR.
From the Allergies Field, you can view the list of all allergies, including all contrast allergies.
Double click on an allergy to read comments about the reaction.
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Kahlon et al/Standardization of CT Contrast Media Practices 565
he patient’s reaction information was retrievable viaMR at any site in the system.To monitor the efficacy of these process changes, the
T contrast reaction monitoring dashboard was ex-anded to track compliance with entering CT contrasteactions into the EMR and categorizing CT contrasteactions per the ACR’s CT contrast reaction classifica-ions.
ffects of Change
he CT contrast media administration policy was ap-roved by a networkwide quality and patient safety com-ittee and is consistently being used as a guideline forT contrast media administration. The CT contrast IVatient questionnaire and the adverse drug event formere implemented at each hospital and are being used to
creen patients for risk for contrast reactions and forocumentation of reactions in conjunction with theMR. The CT contrast reaction monitoring dashboard
s updated and reviewed regularly to monitor compliancend to identify opportunities for improvement.
The EMR training was well received. The implemen-ation of the process was simple and successful, withoutny roadblocks. Technologists, nurses, and in some casesadiologists are able to view patients’ CT contrast reac-ion information well before their examinations, thusiving staff members a chance to contact the patientsbout premedication, if required. In addition, if a new
NameMRN DOB, Age, SexNameMRN DOB, Age, Sex
ig 3. Electronic medical record allergy repository sc
atient has a reaction, hospital staff members are able to r
ecord the information into the EMR, which is thenvailable for future visits.
ext Steps
ext steps are to further enhance the allergy repositoryection of the EMR so that relevant contrast reactionnformation is captured in a manner that is standardizednd auditable. Currently, much of the relevant contrasteaction information, including the grade of the reaction,ust be tracked as free text in the comments section of
he EMR’s allergy repository. This approach does notromote consistent, standardized entry of relevant CTontrast reaction information. Furthermore, the infor-ation is not easily auditable or analyzable. The team has
egun preliminary meetings with the information tech-ology department and various stakeholder groups toake the steps necessary to enhance the EMR allergyepository to have more structured fields for consistent,tandardized, and auditable tracking of relevant contrasteaction information.
Once these EMR enhancements have been made, theext step is to integrate CT contrast decision support
nto our radiology order entry systems to provide notifi-ation at the time of ordering about patients who havead previous CT contrast reactions. This information isarticularly important because patients with histories ofeactions to contrast have been shown to be at increased
4) In the Comments field enter:- The date of reaction- Grade I, II, III- Recommendations for
future studies
5) When finished, click “OK”
2. Select applicable reaction(s), then click “Add”
3. Enter text for additional reaction(s) as needed, then click “Add”
1. Enter the SpecificContrast Agent.
4) In the Comments field enter:- The date of reaction,- Grade I, II, III, and- Recommendations for
future studies.
5) When finished, click “OK.”
2. Select applicable reaction(s), then click “Add.”
3. Enter text for additional reaction(s) as needed, then click “Add.”
1. Enter the SpecificContrast Agent.
enshot.
isk for future reactions to contrast media [2].
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566 Journal of the American College of Radiology/Vol. 6 No. 8 August 2009
ONCLUSION
atient safety continues to be a key issue in health care.arge health care systems with varied hospital cultures,nvironments, and practices are continually challengedo provide safer and higher quality patient care. Compli-nce with standards and regulations from the Joint Com-ission and other relevant organizations, such as theassachusetts Coalition for the Prevention of Medical
rrors, must also be maintained. We have shown that it iseasible to improve and standardize procedures for CTontrast administration at a large integrated health careystem, and we believe that such an approach is broadlypplicable.
CKNOWLEDGMENTS
his project would not have been possible without thealuable input, commitment and contribution fromany people throughout the Partners System. In partic-
lar, we would like to acknowledge the members of theartners Radiology CT Contrast Media Team for theirital role in this project’s success. The team membersnclude: Eileen Bozadjian, RN, BSN, Joseph Fay, MM,T(R), Peg Houghton, RT(R)(CT), Irene Tate, RT(R),inda Plouffe, RT(R), Stuart Hooton, RT(R), Lauraosey, RT(R), Brian McIntosh, RT(R), Michele Rogal-ki, RT(R), R. Jason Webb, Sanjay Saini, MD, MBA,
all, Paula Snavely, Kenneth Hahn, Karen Whitman,lison Gersten, Patricia J. Carchidi, Karen G. Grant,
ames Thrall, MD, Steven Seltzer, MD, James Mastro-atteo, MD, Marjorie Blundon, and Ronald J. Don-
aster.
EFERENCES
. Ouellette-Piazzo K, Asfaw MB, Cowen J. CT Healthcare Failure ModeEffect Analysis (HFMEA®): the misadministration of IV contrast in out-patients. Radiology Management. Available at: http://www.ahraonline.org/AM/Downloads/OnlineEd/2007JanuaryFebruary2.pdf. AccessedMay 20, 2009.
. Morcos SK. Acute serious and fatal reactions to contrast media: our currentunderstanding. Br J Radiol 2005;78:686-93.
. Namasivayam S, Kalra MK, Torres WE, Small WC. Adverse reactions tointravenous iodinated contrast media: a primer for radiologists. EmergRadiol 2006;12:210-5.
. Powe NR, Moore RD, Steinberg EP. Adverse reactions to contrast media:factors that determine the cost of treatment. AJR Am J Roentgenol 1993;161:1089-95.
. American College of Radiology. Manual on contrast media (version 6).Reston, Va: American College of Radiology; 2008.
UPPLEMENTARY DATA
upplementary data associated with this article can beound, in the online version, at doi:10.1016/j.jacr.2009.
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