Independent Health Facilities: Nuclear Medicine Clinical Practice Parameters and Facility Standards

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    The deadline to provide feedback is March 28, 2018.

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    In accordance with the College’s regular review cycle, the Independent Health Facilities (IHF) program’s “Clinical Practice Parameters and Facility Standards for Nuclear Medicine” have been updated. The document is designed to assist physicians in their clinical decision-making by providing a framework for assessing and treating clinical conditions in nuclear medicine facilities.
    The College is inviting feedback from the profession and other relevant stakeholders on the updated draft IHF Clinical Practice Parameters and Facility Standards for Nuclear Medicine, which is an update to the 2011 document.

    Background 

    The primary purpose of this document is to assist physicians in developing their own quality management program and act as a guide for assessing the quality of patient care provided in nuclear medicine facilities.

    The Independent Health Facilities Act (IHFA) gives the College of Physicians and Surgeons of Ontario the primary responsibility for carrying out quality assessments in Independent Health Facilities, which includes responsibility for developing and regular updating of clinical practice parameters and facility standards.

    Key Changes in the Revised Draft Parameters

    The revised parameters now feature numbered sections/subsections within each Chapter for ease of reference, as well as the following updates/additions:

    VOLUME 1: FACILITY STANDARDS

    • Chapter 1: Staffing–– In addition to updating staff roles/responsibilities, the following changes were made:
        • 1.1 – Licensee responsibilities (in relation to staffing a facility) that must be performed in collaboration with the Quality Advisor are included in the overview; this includes, but is not limited to the requirement that all staff remains current with the standards for infection control by obtaining online training through Public Health Ontario, which must be done on annual basis, and must be documented/signed-off and maintained on site.
        • 1.3.2.1 – If the Quality Advisor has reasonable grounds to believe the licensee is not complying with the licensee’s obligations to ensure appropriate qualifications of staff, and services meeting the standard, the Quality Advisor must inform the Director of Independent Health Facilities  (emphasized now, but always been a requirement)
        • 1.3.2.2 – In order to determine appropriate Infection Control training of staff, the Quality Advisor must complete Infection Prevention and Control’s Checklist for Infection Prevention and Control (IPAC) CORE Elements in Clinical Office Practice, and must verify completion of relevant training by all staff.
        • 1.4 – Where the Quality Advisor’s scope of practice does not include all services provided on the licence, she or he must appoint Medical Lead(s) for each applicable service.   Specifically, the Medical Lead must be a physician with adequate expertise to assist with IHF staff compliance with policies and procedures set out by the Quality Advisor, especially as it relates to monitoring and reporting on the quality of services for each additional service.
        • 1.7.1 – MRTs performing BMD must obtain certification through the either the Ontario Association of Radiologists (OAR) or the International Society of Clinical Densitometry (ISCD).
    • Chapter 2:  Facilities, Equipment, and Supplies – This Chapter has been expanded significantly, and now includes expectations related to:  2.2.1- Infection Control; 2.2.2 – Eye Wash Stations; 2.2.3 – Radiopharmaceuticals used in the facility; 2.2.4 –Instrumentation;  2.3 –  Equipment Quality Control, including  Gamma Cameras (2.3.1), Well Counter, Dose Calibrator and Survey Meters (2.3.2), Dual Energy X-Ray Absorptiometers (bone densitometers – 2.3.3), 2.4 – Nuclear Medicine Reporting Stations, and; 2.5 Aging Equipment.  Please refer to all sections for details.
    • Chapter 3:  Policies and Procedures – this more robust Chapter now outlines a number of areas in which facilities must have policies and procedures, including but not limited to:  Equipment Maintenance (3.3.5), Emergency Procedures and Safety Policies (3.3.6) and Infection Control (3.3.8); below are some of the more significant changes (not the only ones) for which policies and procedures must be in place:
        • 3.3.2 – Facility Staff
          • Staff responsible for cleaning, disinfecting, sterilizing, and/or reprocessing of medical equipment must complete appropriate training, including manufacturer’s training.  To determine appropriate training, the Quality Advisor must complete Infection Prevention and Control’s Checklist for Infection Prevention and Control (IPAC) CORE Elements in Clinical Office Practice.
          • All staff remains current with the standards for infection control by obtaining online training through Public Health Ontario, which must be done on annual basis, and must be documented/signed-off and maintained on site.
          • Safety education/training for medical and non-medical staff (which is documented and maintained on site) that addresses areas mandated by the Ontario Government (AODA, WHMIS 2015, etc.).
          • Orientation for all new staff to ensure adequate training (i.e. review of policy and procedure manuals, modality-specific protocols, and all safety training), which employees must sign off indicating that they have successfully completed all of the training.
        • 3.3.4 – Pharmaceutical Safety – policies & procedures for radiation safety and radiopharmaceuticals quality control, and a program to evaluate technical performance of instruments.
        • 3.3.8 – Infection Control – facilities must maintain up-to-date general Infection Control policies (e.g. environmental cleaning, etc.) as well as policies and procedures related to hand hygiene (3.3.8.1), “at risk” patients (3.3.8.2), as well as others.
    • Chapter 4:  Requesting and Reporting Mechanisms – This Chapter was expanded considerably and is largely based on the Canadian Association of Radiologists Practice Guidelines for Communication of Diagnostic Imaging Findings (2010) with modifications to content to reflect the practice of nuclear medicine.   Of particular note, it is recommended that nuclear medicine physicians use their best efforts to ensure the written final report is made available to the ordering physician who is responsible for the clinical follow-up within 2 business days.
    • Chapter 5:  Quality Management – this Chapter now called “Quality Management” (previously entitled “Providing Quality Care”) is more comprehensive, and includes:
        • 5.1 – The Quality Advisory Committee must consist of at least the Quality Advisor, licensee, PACS administrator and site-specific Charge health professionals (e.g. physician, technologist) who provide health services (representing each modality) at the IHF.
        • 5.1 -  The Quality Advisory (QA) Committee meets a minimum of 2 times per year (or more often, as needed), and a list of regular agenda items that QA Committee meetings must include; also the licensee is required to attend all meetings.
        • 5.2/5.3/5.4/5.5 – Quality Management Program goals, as well as Components of a Quality Management Program, as well as details on how that program should be monitored.
    • Chapter 6:  Quality Management – this Chapter now called “Quality Management” (previously entitled “Providing Quality Care”) is now more comprehensive, and includes:
        • 6.1 – The Quality Advisory Committee must consist of at least the Quality Advisor, licensee, and a minimum of 2 site-specific Charge health professionals (e.g. nurse, technologist) who provide health services at the IHF.
        • 6.1 – The requirement that Quality Assurance (QA) Committee meets a minimum of 2 times per year (or more often, as needed), and a list of regular agenda items that QA Committee meetings must include; the licensee must also attend all meetings
        • 6.2 – Quality Management Program goals should include, amongst other items, a review by the QA Committee of the availability of the services at regional dialysis programs for services not provided by the facility, i.e. appropriate patient referrals to multidisciplinary team services at regional dialysis programs might include: dietary, medication and personal/social concerns; vascular access creation, monitoring and servicing; potential self-care and home dialysis options; transplant referrals and work-up facilitation, and; conservative/palliative care discussion and management.
        • 6.4 – Components of a Quality Management Program, as well as details on how that program should be monitored.

    VOLUME 2:  CLINICAL PRACTICE PARAMETERS

    In addition to Chapter 21 (Bone Mineral Content by Dual Energy Absorptiometry) being removed, all other Chapters were updated with only common clinical indications listed (i.e. not every clinical indication); in addition, the following updates were made:

    • Chapter 6:  First Transit with or without Blood Pool Images – Chapters 7 & 8 of the 2011 parameters have been blended into one Chapter and updated.
    • Chapter 7:  Infection and Inflammation Scintigraphy – this is a new Chapter
    • Chapter 12:  Parathyroid Scintigraphy – this is a new Chapter
    • Chapters 15:  Renal Scintigraphy – Chapters 15, 16, 17 and 18 from the 2011 parameters were blended into one Chapter and updated.
    • Chapter 21: Solid Gastric Emptying – this is a new Chapter
    • Chapter 22:  Radiopharmacy Best Practice Standards – this is a new Chapter

    VOLUME 3:  FACILITY STANDARDS & CLINICAL PRACTICE PARAMETERS FOR PET-CT

    Information pertaining to PET & CT which was embedded in Volumes 1 and 2 (of the 2011 parameters) was extracted, updated, and moved to a new volume of its own – Volume 3.    This was done to make it easier for facilities that also perform PET & CT to easily recognize the additional Facility Standards and Clinical Practice Parameters that apply to them.   Refer to Chapters 23 & 24.

    VOLUME 4:  TELERADIOLOGY (PACS)

    The “American College of Radiology White Paper on Teleradiology Practice: A Report from the Task Force on Radiology Practice” was added as additional information to this volume, and the CPSO Telemedicine Policy was updated.

    APPENDICES

    • The following documents were removed as they are outdated:  Ontario Tripartite Nuclear Medicine Advisory Committee Criteria for Physicians in Medical Charge of an In Vivo Nuclear Medicine Facility & Recommended Guidelines for Preventing Allergic Reactions to Natural Rubber Latex.
    • The following sample surveys were added: Sample Referring Physician Satisfaction Survey and Sample Patient Satisfaction Survey.

    Have Your Say

    The College welcomes feedback from members of the profession and any other stakeholders who wish to comment or propose revisions to the draft IHF Clinical Practice Parameters and Facility Standards for Dialysis.  Please be sure to quote the specific numbered sections or subsections to which your comments relate when providing feedback. The consultation deadline is Wednesday, March 28, 2018.  Provide your feedback by email, or send a letter.

    Next Steps

    Feedback provided on the draft IHF Clinical Practice Parameters and Facility Standards for Nuclear Medicine will assist the College in determining what revisions may be required.  Once the document is finalized, it will be posted to the CPSO website.

     

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    Attention: Nuclear Medicine Standards