UCSD Musculoskeletal Radiology bonepit.com Contrast media use

ABSTRACT:

This Policy and Procedure defines the responsibility and accountability for the acquisition, storage, control, distribution, administration, monitoring and disposition of contrast media.  In addition, guidelines for the prevention, diagnosis and treatment of contrast media reactions after intravascular injection are included, and a reference to reduce the chance of inducing contrast media nephrotoxicity is presented.

RELATED POLICIES:

UCSDH MCP 320.4, “Medication Preparation, Labeling and Administration”

UCSDH MCP 321.3, “Patient Treatment and Medication Orders”

UCSDH MCP 321.6, “Medication Errors and Reporting”

UCSDH MCP 321.8, “Adverse Drug Reaction and Reporting”

UCSDH MCP 339.1, “Consent for Anesthesia, Surgery, Special Diagnostic or Therapeutic

                                   Procedures”

UCSDH MCP 393.1, “Central Venous and Arterial Catheter Management and Care”

UCSDH MCP 803.1, “Code Blue -- Adult/Pediatric”

I.          DEFINITIONS

A.  Authorizing Prescriber –Radiologist or other licensed prescriber authorized to order contrast media.     

B.  Imaging Drugs include contrast and biological products, including radiopharmaceuticals (SPECT or PET), intended for use in medical imaging. This is generally consistent with the term contrast agent.

II.         POLICY

A.  A Radiologist is appointed liaison to Pharmacy to assist in the review of policies and usage of contrast in diagnostic imaging.  Under his/her direction and guidance, and in collaboration with the Department of Pharmacy and the Pharmacy and Therapeutics (P&T) Committee, the Diagnostic Imaging Department is responsible for the storage, control, distribution, administration and monitoring of all radiographic contrast media used in Diagnostic Imaging.  Contrast agents used in other divisions will be supervised by the Director of that division.

B.  Contrast agents are used in imaging procedures to facilitate the differentiation of body tissues using imaging devices and are subject to regulatory, licensing and Joint Commission requirements. 

C.  Prior to the administration of contrast and other medications, complete orders or an approved protocol is required. 

D. The formulary of contrast media will be reviewed at least annually by the P&T. New agents should be included in a radiology department formulary review and are included the yearly P&T formulary review.  

E.  Authorizing Prescriber dictated report shall include signature, PID number, date, and time including type and volume of contrast administered.

F.   Standard protocols and procedures with contrast media will be reviewed by pharmacy and approved by the P&T.

G.  The following patient information is accessible when needed (except in emergent situations) to healthcare providers in the medical record [MCP 321.3]:

1.   Age

2.   Sex

3.   Current medications

4.   Diagnosis, comorbidities and concurrently occurring conditions

5.   Relevant lab values

6.   Allergies and past sensitivities

7.   Weight and height, as appropriate to the patient

8.   Pregnancy and lactation status, as appropriate to the patient.

H.  All contrast agents/medications administered should have orders or protocols and will be documented on appropriate medication administration record (MAR) or other appropriate documentation system.   Documentation must include type of contrast, route and volume administered.

I.    Contrast agents may be administered by the following practitioner within their scope of practice:  

1.   Authorizing Prescriber

2.   Nurse Practitioner         

3.   Nurse [or student under direct supervision]

4.   Radiology Technologist and Nuclear Medicine Technologist with appropriate supervision (or student radiology technician under direct supervision).

5. GI Technician [under direct supervision of the prescriber].

J.   All patients will be screened for allergies and previous adverse events to contrast media administration.

K.  Patients will be screened for contrast media nephrotoxicity prevention in accordance with guidelines set forth in WD1111.

L. IV Contrast 

1.  The Authorizing Prescriber or qualified individual will be in the immediate area to respond to emergencies when contrast is injected by radiologic technologists or nuclear medicine technologists within their scope of practice.

M.  Oral and rectal contrast media

1.   All patients will be screened for allergies and previous adverse events to contrast media administration.

 III.       PROCEDURES AND RESPONSIBILITIES

A.        Technologist/Nurse Responsibilities

1.   Completion of a Patient Questionnaire [See D Form D322x for CT/X-ray; D2969 for MRI contrast form or equivalent assessment prior to contrast media administration.

2.  The screening assessment is documented in the patient’s medical record.

3.   Comparison of the Screening tool against the contrast specific trigger form. 

4.   Provide contrast specific patient education verbally or in writing.

B.  Authorizing Prescriber/s Responsibilities

1.   Address any concerns identified by the technologist/nurse with the History and Screening tool or equivalent.

2.  Assess renal function, calculate dosages and document orders.

3.  Address potential drug-contrast media interactions, if applicable.

4.  Provide appropriate supervision for contrast administration.

5.  Review the requested exam, and modify ordered contrast procedure as appropriate.

6.  Be available to assess patients for allergic and contrast reactions, extravasations, order medications and provide timely intervention in the event of a patient emergency.

7.  In an emergency, such as for a stroke evaluation, the decision whether to give contrast agent will be based upon the Prescriber's judgment of the risk/benefit ratio. If the information from the contrast imaging study is critical for patient care, the contrast agent may be given without consideration of allergy or renal function. The Prescriber giving the contrast must be prepared to handle an emergency contrast reaction.

C.  Intravenous Access

1.  Use of existing access routes:

a)   Only power-injection rated PICC lines, Ports, and Central lines are approved for Power injector use.

b)   Pre-existing IV lines will be flushed with 10mLs of saline flush, to ensure patency, prior to and after contrast injection.

D.  Prevention of Nephrotoxicity with Iodinated Contrast Media and Gd-based Contrast Agents for MRI [Refer to Form D 1111]

E.  Allergic Type Contrast Reaction Prevention [Refer to Form WD 1111]

F.   Diagnosis and Management of Contrast Reaction [Refer to Form WD 1111]

G.  Diagnosis and Management of Contrast Media Extravasation [Refer to Attachment A]

H.  Documentation

1.   All doses of contrast media will be documented in the medical record.

      a)  Date and time of administration

      b)  Contrast type, route and dose/volume used

      c)  Pre-treatment and dose, if given

      d)  For contrast reactions requiring medical intervention, include the:

1)   The reaction description

2)   Any treatments provided

                        i) If there is harm or the potential to harm the patient

                        there should be an immediate report of a significant

     administration error/adverse drug reaction made to the attending (or covering) physician.

                                 ii)  Technologist/RN will document the reaction in the

medical record and complete an event report (i.e., iReport) including the reaction description and any treatments provided.

IV.    ATTACHMENTS

Attachment A: Contrast Extravasation Guidelines

V.       FORMS

          Form WD 1111: Intravenous Contrast Media Guideline

VI.       RESOURCES

          CMS Appendix A: 42CFR 482.25(b) (6)

VII.    REGULATORY REFERENCES

--Title 22, California Code of Regulations

--The Joint Commission (TJC), Medication Management and includes 05.01.01, 05.01.07

--Medicare Conditions of Participation

--California Board of Pharmacy

VIII.     APPROVALS

This policy and procedure was approved by the following committee(s):

Committee Name:                                                                Date Approved:

Pharmacy and Therapeutics                                            

Medical Staff Executive Committee