Tech Best Practice

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Best Practice in Nuclear Medicine

Part 1A Technologists Guide

European Association of Nuclear Medici

ne


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ContributorsIgnasi Carri M.D.

President o the EANM

Proessor o Nuclear Medicine

Autonomous University o Barcelona

Director, Nuclear Medicine Department

Hospital Sant Pau

Barcelona, Spain

Suzanne Dennan (*)

Deputy Radiographic Services Manager,

Dept. o Diagnostic Imaging

St. Jamess Hospital

Dublin, Ireland

Wendy Gibbs

Delivery Manager

Dept. o Nuclear Medicine

Guys and St. Thomas Hospitals

London, United Kingdom

Julie Martin

Director o Nuclear Medicine Service


Guys and St. Thomas Hospitals

London, United Kingdom

Brendan McCoubrey

Radiation Saety OcerDept. o Diagnostic Imaging

St. Jamess Hospital

Dublin, Ireland

Sylviane Prvot

Chair, EANM Technologist Committee

Chie Technologist, Radiation Saety Ocer

Service de Mdecine Nuclaire

Centre Georges-Franois Leclerc

Dijon, France

Helen Ryder

Clinical Specialist Radiographer


St. Jamess Hospital

Dublin, Ireland

Linda Tutty

Senior Radiographer


St. Jamess Hospital

Dublin, Ireland

Anil Vara

Clinical Modality Manager Nuclear Medicine


Royal Sussex County Hospital

Brighton, United Kingdom

Editors

Suzanne Dennan (*)

Sue HuggettSenior University Teacher

Dept. o Radiography

City University, London, United Kingdom

This booklet was sponsored by an educational grant from Bristol-Myers Squibb Medical Imaging . The views expressed

are those of the authors and not necessarily of Bristol-Myers Squibb Medical Imaging.


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ForewordSylviane Prvot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

IntroductionIgnasi Carri M.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Section 1 Managing a Nuclear Medicine Service 7

Anil Vara . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

1.1. Patient Workow and Ecient Scheduling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

1.2. Stock Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

1.3. Cost Implications Budgeting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

1.4. Risk Assessments and Incident Training/Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

1.5. Business and Strategic Planning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

1.6. Audit/Clinical Governance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

1.7. Accreditation Quality Awards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18

Section Guidelines / Policies / Protocols 19

2.1. Available Guidelines

Brendan McCoubrey. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .192.2. Protocols and Policies in Nuclear Medicine DepartmentsHelen Ryder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20

2.3. Clinical Research PoliciesLinda Tutty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29

Section Staf Aspects o Best Practice

3.1. Best Practice or Recruitment and SelectionWendy Gibbs and Julie Martin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32

3.2. Best Practice or Induction

Wendy Gibbs and Julie Martin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .383.3. Best Practice or AppraisalWendy Gibbs and Julie Martin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46

3.4. Education and TrainingSuzanne Dennan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48

3.5. Lielong Learning and CPDSuzanne Dennan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51

3.6. Multidisciplinary Team WorkingLinda Tutty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54

Reerences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56

Contents


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ForewordSylviane Prvot

One o the major achievements o the EANM

Technologist Committee in the past 2 years

has been the publication o a series o bro-

chures Technologists guides that was ini-

tially planned with two main goals: to en-

courage Nuclear Medicine Technologists

(NMTs) reection on the quality o their daily

practice and to advance it i necessary.

The aim o this third volume is to provide

an introduction to best practice in Nuclear

Medicine considering three main items : man-

agement o a modern day Nuclear Medicine

service, clinical guidelines & protocols, man-

agement o human resources. The impact o

policy and legislation on best practice will be

the purpose o a second part to be published

at the EANM Congress 2007 in Copenhagen.

I am grateul or the eorts and hard work o

all the contributors, who are the key to the

content and educational value o this book-

let. The most essential and relevant aspects

o best practice are emphasized here. Many

thanks to Suzanne Dennan or her dedication

to the success o this guide. This publication

wouldnt have been possible without Bristol-

Myers Squibb Medical Imaging support. Their

collaboration and generous sponsorship was

greatly appreciated.

Quality is not just a nice concept : quality is a

state o mind. I hope this brochure will meet

the expectations. Contributing to the qual-

ity assurance o Nuclear Medicine practice it

may also become a useul tool or motivated

technologists in the optimization o the overall

quality o healthcare in Europe.

Sylviane PrvotChair, EANM Technologist Committee


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IntroductionIgnasi Carri M.D.

Nuclear Medicine departments oer a large

diversity o diagnostic and therapeutic pro-

cedures, which oten play a central role in pa-

tient management. At the same time, the feld

is constantly evolving with new procedures

being continuously introduced. In such a rich

and developing scenario, adherence to best-

practice guidelines becomes crucial to oer

best patient care.

Nuclear Medicine technology is a demanding

and sophisticated proession. The continuous

developments in technology, radiopharmaceu-

ticals, procedures and patient care make it one

o the most rapidly evolving health care proes-

sions. For example, novel targets or imaging

have emerged, such as labelled glucose or the

imaging o cancer, labelled somatostatin tracersor the imaging o neuroendocrine disease, beta

CIT homing onto the dopamine transporter or

the investigation o patients with movement dis-

orders. Progress is coming in the imaging o the

Alzheimers disease, the imaging o atheroscle-

rotic plaque and the imaging o angiogenesis

and hypoxia. Sentinel lymph node detection has

changed the surgical management o patients

presenting with early breast cancer. At the same

time, all diagnostic procedures have benefted

rom major progress in instrumentation; and in

the last 5 years, the emergence o multimodal-

ity imaging has become routine. Conventional

gamma cameras have been linked to advanced

CT scanners (SPECT/CT) and modern PET scan-

ners have been linked to multi-slice CT devices

(PET/CT).

Nuclear Medicine therapy has also been grow-

ing ar beyond the established treatment o

benign and malignant disease o the thyroid. I-

131 when linked to metaiodobenzylguanidine

is used in the treatment o neuroendocrine

malignancies, such as pheochromocytomas

and neuroblastomas. Newer ligands target-

ing the SS2 receptor subtypes are emerging,

labelled with Yttrium 90, Lutetium 177 andother radionuclides. Pain palliation in ad-

vanced metastatic and skeletal prostate and

breast disease has become available, with one

third o patients showing excellent response

to a variety o radionuclides, including stron-

tium 89-chloride, rhenium-186 as etidronate,

samarium-153 as ethylene-diaminetetrameth-

ylene phosphonate. Several labelled antibod-

ies have been entered in clinical trials andsome have now been approved as specifc

treatment options, such as Zevalin or Yttrium-

90 labelled ibritumomab tiuxetan and Bexxar

I-131 labelled tositumomab.

With such continuing developments and in-

novation, best-practice may become a mov-

ing target. Clearly, best-practice guidelines

must be developed and implemented at the

European level that help Nuclear Medicine

departments to provide best patient care. Up-

dated procedural and clinical guidelines are

available rom the EANM website or many o

the well established diagnostic and therapeu-

tic procedures. Adherence to such guidelines

is highly desirable to harmonize patient care

across the diversity o European countries. Eu-


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ropean Nuclear Medicine technologists prac-

tice Nuclear Medicine in departments where

most o these procedures are perormed in a

patients diagnosis or ollow-up. As members

o their institutional health care team, they

also unction as patient advocates, educators,

health care researchers, technical and therapy

specialists, and interdisciplinary consultants

and play a key role to oer best clinical prac-tice. Nuclear Medicine must embrace the prin-

ciples o best-practice as the basis or clinical

judgement, within the context o working as

part o a multi-disciplinary team in medical

diagnosis and therapy. Within such multi-disci-

plinary teams, Nuclear Medicine technologists

must play a leading role in establishing clinical

standards and clinical protocols.

In order to oer best practice, continuing edu-

cation is essential. The education process in

Nuclear Medicine includes graduating rom

an accredited programme, completing a

summary o clinical competence and com-

pleting a proessional certifcation examina-

tion when available. The education process

assures that Nuclear Medicine technologists

have the knowledge, skills and judgement to

be competent health care providers in their

highly specialized discipline. In addition, lie-

long learning is a core value or all health care

proessions. Thereore, entry-level education in

Nuclear Medicine must be supported by both

ormal and sel-directed proessional devel-

opment programmes. All these programmes,

including cognitive, aective and clinical com-

petence, must be part o best-practice codes

in any Nuclear Medicine department.

Like all healthcare proessions, Nuclear Medi-

cine must move with the times, changing and

adapting its principles and relationships, ac-

knowledging the expectations o patients and

the developing practice o other healthcare

disciplines. Like all healthcare proessions, onlyby understanding, accepting and adapting

to these changes can Nuclear Medicine oer

best-practice and retain its relevance within

medicine and society.

Ignasi Carri, M.D.

President, EANM


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Section 1 Managing a Nuclear Medicine Service1.1. Patient Workow and Ecient Scheduling

Anil Vara

Introduction

An ecient Nuclear Medicine department

relies mainly on good scheduling o patients

or an ecient workow. Nuclear Medicine

has various types o examinations, each with

its own time scale, preparation, and various

complications. Diagnostic imaging is the most

common type o examination most centres

schedule routinely.

TIME STUDY PATIENTS NAME COMMENTS

09:00 URGENT BONE

09:15/09:30 RBC/MECKELS/MAG3

09:45

10:00 BONE/DMSA INJ 110:15

10:30 LUNG PERFUSION

10:45 BONE/DMSA INJ 2

11:00 BONE/DMSA INJ 3

11:15 BONE/DMSA INJ.4

11:30 3 PHASE BONE 5

12:00 3 PHASE BONE 6

12:15 URGENT BONE SCAN

13:00 BONE/DMSA SCAN 1


13:45


14:15

14:30 BONE SCAN 4

14:45

15:00 BONE SCAN 5

16:30 BONE SCAN 6

Diagnostic Imaging

Diagnostic imaging makes up the bulk o

examinations in Nuclear Medicine. Ecient

scheduling or this is mainly dependent on

sta availability, gamma camera numbers,

and gamma camera types. Some centres may

operate with a single gamma camera, whilst

some departments may have multiple gamma

cameras at their disposal.

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Table 1: Example outline o a day list illustrating exibility in Nuclear Medicine exam type.Courtesy o Kingston NHS Hospital, Surrey; Vara 2001


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One Gamma Camera Department

Centres that have only one gamma camera

are most likely to schedule various types o

examinations during a working day. Careul

planning and organisation is critical to achieve

this, in light o the complexity involved in vari-

ous Nuclear Medicine exams. Block booking

particular exams could be dicult to achieve,

whilst having the exibility or all types o ex-ams over a working day would be more e-

cient. Table 1 illustrates an example o a typical

days workow on a single gamma camera.

The outline o the example takes account o

the various camera times required or each

exam, whilst ully utilising all the capacity

available to schedule the various exams. This

type o day diary can be easily set up or singlecamera departments, but care must be given

on examinations that are higher in demand.

Systematic review o all workows should take

place regularly, especially ollowing a protocol

review.

Multiple Gamma camera departments

Scheduling on multiple gamma cameras can

be exible, but the main advantage is that

block booking o particular exams can be

achieved more eciently than in single cam-

era departments. The option o block booking

or higher demand studies, or example Myo-

cardial Perusion studies such as Octreotides

or MIBG can be better streamlined, not hin-

dering common types o work such as Bone

scanning etc.

Other types o examinations

Scheduling non-imaging examinations

alongside diagnostic imaging is needed in

most Nuclear Medicine departments. These

could be exams such as GFR, red cell mass

or therapeutic administrations. In-vitro based

exams are mainly perormed by trained sta

that are commonly multi-tasking and involved

in other areas. Rotating sta through all areasmaximises expertise and is best or exibility

in scheduling non-imaging work alongside

diagnostic imaging. Scheduling in-vitro work

has to be carried out with care to ensure ad-

equate capacity is maintained at all times in

all areas o the department.

Therapy is very dependent on key proes-

sionals such as consultants and/or medicalphysicists. Usually in this case, scheduling o

these patients is independent o other Nucle-

ar Medicine work, but attention is needed i

technological sta have delegated responsi-

bility in Therapy.


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Section 1 Managing a Nuclear Medicine Service1.2. Stock Control

Anil Vara

Introduction

Stock control in Nuclear Medicine is an es-

sential task or the ecient operation o the

Nuclear Medicine department.

The types o stocks routinely handled are:

1. Radiopharmacy consumables

2. Clinical consumables3. Pharmacy consumables

4. Administrative consumables

1. Radiopharmacy Consumables

Radiopharmacy consumables include cold

kits, nuclides and items used or radiopharma-

cy production. Cold kits have to be careully

managed, as their requirement is very much

dependent on the particular demands orcertain types o examinations, which can vary

over quite short periods o time. Most centres

have purpose built databases or spreadsheets

or managing these stocks. These are usually

or the purpose o recording incoming stock

and auditing the level o use based on the

service need. Such databases allow a concise

record allowing all aspects o stock control to

be monitored but there is still an element o

good communication needed between the

production service and the diagnostic service

to reduce the occurrence o overstocking and

to accommodate any service changes. When

ordering cold kits and 99m Tc generators, this is

best accomplished by a standing order with the

supplier, but a regular stock take every month

is essential in conjunction with this, in order to

minimise costs and waste. Commercial com-

panies are now oering sotware packages to

carry out the overall management o radiophar-

macy stock, with options built in to warn o low

stock levels and automatic updating.

Ordering long-lived radiopharmaceuticals such

as 111In Octreotide, I131MIBG etc. is usually carried

out on a per usage basis.

2. Clinical Consumables

Clinical consumables range rom requently

consumed items such as syringes, needles,

gloves, sharps bins etc to items that are used

less requently such as, ventilation kits or aero-

sols, specialised nursing aids etc.

The golden rule is not to overstock on theseitems, which is a common practice in some

Nuclear Medicine departments. This can lead

to excess requirement or storage space, the

risk o items expiring and o accumulating

unused items which would incur costs. Com-

monly, these types o stocks are controlled and

ordered as a common pool with other modali-

ties such as Radiology and CT. By averaging out

consumption, this does achieve an adequate

stock o clinical consumables which can be

reviewed weekly or every ortnight. Most hos-

pitals operate an online ordering system, direct

to their stores and even set up standing orders.

Standing orders would be practical or consum-

ables that have average usage (per week or

example) and the average usage is sustained.

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3. Pharmacy Consumables

Nuclear Medicine routinely has to stock both

drugs that are commonly used as part o

the examinations and essential drugs which

are used or intervention when aced with

emergencies. Usually a standing order with

the pharmacy department would be best to

manage the incoming stock o drugs with

the advantage o cross charging made easierto budget or every month. Additional drugs

can be requested when stock is low. The most

crucial element is that pharmacy drugs are all

checked or expiry regularly and that drugs

used should be replaced as soon as possible.

In these cases, it is oten useul to stock take

once or twice a week so the drugs cabinet

is not in surplus and that all essential drugs

are in stock.

4. Administrative Consumables

These consumables are essential or the e-

fcient clerical operation o Nuclear Medicine.

Again overstocking could result in unneces-

sary costs to the department. The common

practice or most institutes is that administra-

tion consumables are managed by a central

department, which is usually also covering

many modalities other than Nuclear Medicine.

Increasing turnover in this way, it can be en-

sured that stock is well controlled and that

surpluses do not occur.


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11

Financial pressure is always a concern or an e-

fcient operation o a Nuclear Medicine service,

usually associated with overall Health/Trust

service pressures. It is important to manage

the departmental budget properly in order

to have eciency and exibility.

In the UK, departments that are in the NHS

are paid by the activity completed. This iscalled Payment by Results, and requires good

data keeping and strict audit on all activity

within the department, so that all income is

accounted or.

Departmental budgets are usually broken

down into the ollowing components:

1. Pay Sta costs2. Non-Pay All other costs

3. Income Pay that is received by the

department

In the UK it is common practice to cross charge

or internal (within the hospital) and external

(other hospital) work. This would account to

the income the department will receive. Set-

ting up local trading accounts can achieve

this best.

1. Pay

The pay budget is allocated or sta. Once

sta and their unding have been agreed, the

institute accountant will assign an annual bud-

get against each one. Pay budgets should be

reviewed regularly especially when a vacancy

occurs. This would allow a review o the ser-

vice needs at the current time and provide

an opportunity to prove the need or addi-

tional posts and/or restructure sta gradings

to maximise numbers. Reviews o this kind are

essential, as service needs do change and oc-

casionally higher demand areas can be unded

within the existing budget.

2. Non-pay

This budget represents all costs involved in

running the Nuclear Medicine service. These

are usually broken down into individual ac-

counts such as equipment, radiopharmacy,

maintenance, provisions etc. Again, the insti-

tute accountant will place a budget limit to

each account based on an estimate o the true

costs rom previous years. Good managemento this budget is required to prevent over-

spending. Items should be charged to the

correct account so that a review at the end

o the year shows a true reection o where

adjustments need to be made or the ollow-

ing year. Regular (monthly) review o each

account is important, as during the fnancial

year it may be ound that certain accounts are

not being used whilst others are at risk o be-

ing overspent. By making slight adjustments

across accounts, it is possible to balance each

account properly, making the end o year re-

view easier. Occasionally, however, it may be

ound that a budget set against an account

is not used at all until a particular month. An

example o this would be a contract o some

kind, or which a bulk payment is taken in one

Section 1 Managing a Nuclear Medicine Service1.3. Cost Implications Budgeting

Anil Vara


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1

month only. In these cases, accounting meth-

ods can adjust or this so as not to give a alse

impression o the account.

3. Income

Most departments will receive income, mainly

or services to outside institutes usually via

service level contracts or monthly activity re-

charges. These budgets are reviewed at theend o every fnancial year. Managing income

is very important. All activity must be logged

and cross-charged so that regular income

payments are made. Late payments need to

be borne in mind at monthly reviews. I ex-

cess income is obtained, this can be used or

o-setting any other budgets such as pay or

non-pay, but this is rare once annual budgets

are set.


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1

Risk assessments

Risk assessments should be carried out be-

ore any new work within Nuclear Medicine

commences. The most common types o risk

assessments are based on radiation risks and

health and saety issues.

These assessments are drated, usually based

on advice orm the RPA (Radiation ProtectionAdvisor), so relevant sta are aware o risks in

each area o the department. They should be

read by all personnel who would be working

in the assessed areas. The assessments or as-

sociated radiation risk should be drated or

each area o Nuclear Medicine and regularly

reviewed, preerably once a year or i an in-

cident or near miss has taken place. During

the review process, control measures must

be updated to minimise the risk as much as

possible.

The 5 steps to a risk assessment are as ollows:

1. Identiying the hazard

2. Control measures in place

3. Evaluating the risks4. Action plan/records

5. Review

Risk assessments should be kept as simple

as possible and be concise. It is usually best

to produce a series o assessments based on

each room within Nuclear Medicine. An ex-

ample is shown in Table 1:

In the UK, all risk assessments must conorm to

IRR99 regulations (Ionising Radiation regula-

tions 1999). Areas in Nuclear Medicine desig-

nated as controlled or supervised should be

defned within the risk assessment.

Incident training

Unortunately incidents do happen in Nuclear

Medicine, even when assessments are made.

When an incident does occur, it must always

Area Types o risks associated

Gamma Camera roomUnsealed sources, patient contaminants, sealed sources, doses to sta rom

patients

Injection room Dose rates to authorised sta, sealed and unsealed sources,

Waiting area Dose rates rom radioactive patients, patient contaminants

be documented, with records fled. A review

must take place ollowing the incident, so the

risks associated can be minimised urther, i

possible.

The radiation protection supervisor should

have a training programme, which all sta

working in relevant areas o Nuclear Medicine

should undergo, beore commencing work.

The training should consist o the ollowing:

Table 1: Risk assessments

Section 1 Managing a Nuclear Medicine Service1.4. Risk Assessments and Incident Training/Practice

Anil Vara


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1

1. To read and ollow the local rules or the

department

2. To be amiliar with the procedures when a

radiation incident occurs

3. To be aware o the documents that need

to be completed when a incident occurs

4. To be cognisant o the sta that have to be

notifed.

The local rules should be concise and as short

as possible. They should contain key inorma-

tion such as contact details, types o sources

within the department, decontamination

procedures, and systems o work, operational

procedures and contingency plans.

Generic hospital incident logbooks can be

used or logging incidents. Although a pur-pose made record is just as good. Following

an incident, a record should be drated as soon

as possible. Depending on the severity o the

risk, incidents should be ollowed up quickly,

reviewing systems o work to minimise the

risk. All incidents should be discussed at the

next radiation saety committee, where urther

support can be acquired, i needed.


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1

Business planning in Nuclear Medicine is

very important, especially when immediate

or uture changes need to be made. Nuclear

Medicine is a growing area in medicine, and

services have to be adapted in order to meet

the rapid changes that will occur.

Initial planning

When an idea needs to be taken orward, suchas new equipment, sta or even a new tech-

nique, it is important that all the evidence is

available to take the plan orward and make

its possible implementation as smooth as pos-

sible. The types o evidence that should be

considered are:

1. Financial unding and support

2. Any income revenue or other benefts tothe trust/organisation

3. Capacity and demand data or the Nuclear

Medicine department

4. Recommendations and audits rom recog-

nised proessional groups e.g. NICE

(National Institute o Clinical Excellence,

UK) EANM

5. Impact on the service i the plan is

declined

Business case

The business case is the essential docu-

ment, which will allow all the evidence to

be placed together and illustrate options to

be considered or the business proposal. The

business case should be drated accurately

and in conjunction with the trust accountant.

Section 1 Managing a Nuclear Medicine Service1.5. Business and Strategic Planning

Anil Vara

Once a business case is prepared, it is usually

submitted to the trust board or approval and

implementation.

Essentials o the business case

When drating a business case, the ollowing

essential sections should be included:

1. Executive summaryThis section should begin with an introduc-

tion and purpose o the case. Good evidence

such as rom regulatory bodies, government,

commissioning bodies etc is well suited here.

Following this, a section on demand and ca-

pacity o the current service should be includ-

ed. This will be based on graphical representa-

tion o the demand (amount o work entering

the service) and capacity (current sta andequipment) available and any changes pro-

posed that may aect this. Finally, at the end

o this section, a list o options should be listed.

This is called an options appraisal. Although,

you will have evidence to support the new

case, all options should still be considered in

any business case. This should always include

a Do Nothing option, so the business case

reects all possibilities, including the impact

on the service i the trust board rejected the

business case.

2. Economic case

This section should be used or detailing and

arguing the fnance proposed or the case. It

should begin by listing the fnance require-

ments behind each o the above listed op-


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1

tions. This is called an economic appraisal.

All fnance initiatives, including negative im-

pacts, should be included under each option.

Following this, an assessment o the risks and

benefts o this case should be made. This is

very similar to a risk assessment in Nuclear

Medicine, where a scoring method can be

derived and used to measure the positive andnegative aspects o each option. All associ-

ated risks and benefts should be included to

make the case look strong. The outcomes o

the scoring can be presented in a results sec-

tion, ollowed by a simple conclusion.

3. Finance and recommendations

This last section should indicate the amount,

source and pressures o the fnancial supportneeded to justiy the best option. Usually at

this point, prior agreement o the source o

unding will have been obtained and this will

need to be documented here.

The fnal recommendation should highlight

the best option to proceed with. The data

provided in the relevant section should agree

with the departments recommendations, and

i the evidence is clear, usually the business

case is accepted. Occasionally, one or more

options may be suitable; and in these types

o situations it is very dicult to agree on the

case. But, when possible, i there is just one

easible option in the recommendations, it

works to the departments advantage.


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17

Audits (examinations o records to check their

accuracy) and clinical governance (the system

through which organisations are accountable

or continuously improving the quality o their

services and saeguarding high standards o

care, by creating an environment in which

clinical excellence will ourish) are essential

in Nuclear Medicine as with any other part

o medicine. Clinical governance teams (orequivalent) should be set up to perorm this.

The audit group should comprise o essential

sta rom each clinical area. A person specif-

cally employed within speciality areas, such

as Radiology and Nuclear Medicine, would

normally lead on this.

When audit projects are set up, they should

begin with a defnite aim and methodology.Audits within the service should cover the ol-

lowing areas:

1. Change or implementation o clinical

practice

2. Changes in service provisions with best

patient care practice

3. Evidence towards a new business case

The aim o the sub specialty group is to ensure

that best practice is always implemented and

any new evidence that arises can be discussed

or easibility to improve patient management.

Generally once the group agrees to the results,

these are used to implement any changes and

support any urther case. Discussions and

ideas rom these meetings should be taken

Section 1 Managing a Nuclear Medicine Service1.6. Audit/Clinical Governance

Anil Vara

orward to management meetings where fnal

decisions are made. All audits should be well

documented, even published, and available

to any external auditors.


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Section 1 Managing a Nuclear Medicine Service1.7. Accreditation Quality Awards

Anil Vara

Accreditation towards a good Nuclear Medi-

cine service is always an indicator o high

achievement and movement in the right di-

rection. Essentials o a good quality service

should include

1. Good written policies and procedures or

the department

2. Practice that complies well with the localregulations

3. A review structure that covers all aspects

o Nuclear Medicine

4. A department that liaises with other insti-

tutes within a local area and gets involved

with local activities to help maintain a good

level o service.

Well written policies and procedures are es-sential. They help maintain proessional and

sae practice in Nuclear Medicine as well as

help develop the service through audits and

reviews.

Practice in conjunction with regulatory bod-

ies is very important. For example, in the UK,

the Department o Health has written various

documents that require compliance. Although

the practice associated with implementing

these documents will vary rom department to

department, the principles remain the same.

Good communication with other institutes

will help achieve this as well as regular inspec-

tions by the governing bodies to highlight

areas o poor quality. Proessional institutes

such as National and European Nuclear Medi-

cine societies will drat polices and procedures

which should be ollowed.

Reviewing current practice should give an

opportunity to enhance the service or deal

with a concerning situation. Reviews should

be made in line with local or national audit

programmes/data and should be included

across the whole unction o the departmentincluding sta competencies.

Taking the departments work orward to Na-

tional or European meetings is an essential

practice to demonstrate to other institutes

how the department is progressing and to

share new initiatives. Usually single or joint

departmental ventures are undertaken. Most

departments do fnd it dicult to take thisorward, due to service and sta pressures, but

this should be encouraged as ar as possible.

This is why joint ventures can make it easier.


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19

In preparing a document on best practice

in Nuclear Medicine, it is important to draw

on the existing research, which has been

conducted by the various relevant authori-

ties concerned with the provision o a Ra-

dionuclide Imaging service throughout the

world. In particular it is necessary to ocus on

the guidelines which have been ormulated

in the context o evolving European legisla-tion and practice. National interpretation o

European Regulations on the administration

o radioactive substances and dierences in

clinical practice and service delivery mean

that guidelines do not readily apply across

regional and national boundaries. The Euro-

pean Association o Nuclear Medicine (EANM)

http://www.eanm.org recognises the need or

the development o clinical guidelines at aninstitutional level to incorporate those aspects

o the available guidelines that impact on the

tailored service provided by the institution.

O greater relevance than detailed guidelines

covering perormance aspects o individual

diagnostic and therapeutic procedures are

Generic Quality Guidelines, which outline the

perormance characteristics aecting overall

quality. From these Generic Quality Guidelines,

individual institutions should derive specifc

local guidelines covering those practices rel-

evant to their service requirements.

By ollowing the links given, a cross section

o the existing guidelines provided by rel-

evant authorities at both European level and

Section 2 Guidelines / Policies / Protocols2.1. Available Guidelines

Brendan McCoubrey

worldwide can be ound. These guidelines are

resultant rom the research assimilated by the

national and international institutions. A brie

introduction is given concerning the history

o the particular association.

Guidelines are available or download on the

EANM website at the ollowing address :

http://www.eanm.org/scientifc_ino/guidelines/guidelines_intro.php?navId=54

International Links

Further links to the International Associations

and Societies may be ound at the ollowing

address:

http://www.eanm.org/pat_ino/links.

php?navId=57

Nationally produced guidelines can be ound

on each societys website.


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Section 2 Guidelines / Policies / Protocols2.2. Protocols and Policies in Nuclear Medicine Departments

Helen Ryder

A cornerstone o good practice in a Nuclear

Medicine department is the development

and usage o protocols and policies or that

particular unit. O diering origins, protocols

tend to be an amalgam o standard scanning

techniques with local radiological preerences

whereas policies are normally devolved rom

legislation regarding the use o diagnostic

radiation or the health and welare o thepatient.

So who uses these protocols?

The development o protocols is intended to

standardize technical actors, timing o imag-

ing and the views obtained during imaging

to provide the best inormation rom which

the scan may be reported. By making these

protocols available within the department,either electronically or on paper, new or ro-

tating sta/personnel may be kept up to date

on latest changes in techniques. It also acts

as a reerence or examinations that are not

regularly perormed by the department.

Reerence to written protocols can also alert

sta members to the individual needs o the

reporting clinician. Most departments have

more than one member o the medical sta

who undertake and oversee scanning ses-

sions, and adaptations by scanning sta to

their preerred techniques are o vital impor-

tance.

Developing protocols

A starting point in preparing an examination

protocol is to list the technical actors required

to complete the scan. These actors can in-

clude:

Equipment used in a multi-camera de-

partment some equipment may be more

suitable than others. Myocardial peru-

sion imaging generally requires the use o

a multi-tangential dual-headed gammacamera; brain imaging may best be acili-

tated by utilising a dedicated triple-headed

system.

Quality Assurance and pre-set Gamma

Maps when using rotating cameras, or

diering or multiple isotopes, preliminary

QA and gamma maps may need to be per-

ormed or defned.

Radioisotope isotope channel, peak and

acceptance window to be used.

Acquisition Parameters :

Matrix size can vary either or type o acquisi-

tion required (dynamic; planar; tomographic)

or within a specifc acquisition (e.g. The vas-

cular/dynamic and blood pool/static planar

phases o bone imaging). These are usually set

within the acquisition protocol logged onto

the scanning computer.

Type of acquisition e.g. dynamic, static, whole-

body, SPECT, gated.


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1

Time of acquisition/count statistics some im-

ages may be ended by reaching either a time

or count limit, or in terms o gated studies by

the number o cycles completed.

Indications/Contraindications in some cases

the scan requested may not be the most ap-

propriate examination. The Royal College o

Radiologists (UK) in London has produced abooklet which oers guidance in these cases

or a wide range o diagnostic imaging proce-

dures. The booklet is called Making the best use

o a Department o Clinical Radiology and is

available through their website at http://www.

rcr.ac.uk/index.asp. The European Commission

has adapted the RCR reerral guidelines or use

in their guidance document Radiation Protec-

tion 118 Reerral guidelines or imaging, whichis available at the ollowing web address:

http://ec.europa.eu/energy/nuclear/radiopro-

tection/publication/doc/118_en.pd.

Contraindications can apply both or choice o

examinations or, more relevant in departmen-

tal protocols, or medical and physical reasons.

For example when choosing a pharmaceuti-

cal or myocardial stress procedures, it should

be noted that asthmatic patients should not

be given either adenosine or dipyridamole.

Physical limitations may also defne which ex-

amination may be appropriate e.g. diculty in

perorming physical exercise.

Patient Preparation o vital importance in

the production o diagnostic scan results,

Section 2 Guidelines / Policies / Protocols

these should be defned or all examina-

tions perormed in the department. Prepa-

rations should include the need or asting;

hydration requirements; medications to be

halted prior to examination; medication

to be taken pre- and/or post examination.

The timings o such preparations as well as

medication lists etc should be logged both

in the protocols and any inormation sheetssent out to the patient when the appoint-

ment is scheduled.

Scan time delays some examinations re-

quire that scans be perormed at certain

time intervals, be they minutes, hours or

days. These timings should be included in

the protocol listings.

Images/views taken whilst many examina-

tions can be perormed as pre-programmed

imaging e.g. wholebody procedures, others

require a series o static planar images to

be taken to demonstrate the physiology

required. This includes, or instance, the

multi-planar imaging o lung perusion us-

ing Tc99m-MAA. A typical series o the lungs

may include: Anterior; Posterior; Let Ante-

rior Oblique; Right Anterior Oblique; Right

Lateral; Let Lateral. Positional angulations

should be recorded or successul compara-

tive imagery.

Adaptation o protocols although the

ramework o a successul scan is laid down

in the protocol list as above, it should be


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noted that this protocol can be adapted

or the medical condition o the individual

patient or or the requirement o a partic-

ular requesting physician. An example o

this adaptation could be the basic Isotope

Bone Scan. Dierent patient history could

inuence the views taken during the ex-

amination in the ollowing ways:

- metastatic disease --- wholebody scan

plus detailed static planar imaging o

areas o interest.

- osteo- or rheumatoid arthritis --- whole-

body scan plus static planar imaging o

hands and eet

- inection/racture e.g. diabetic oot --- dynamic imaging o area o interest

with three-hour delayed static planar

imaging o relevant areas

- mandibular asymmetry --- static planar

imaging o head plus SPECT imaging o

mandible.

Analysis protocols many nuclear medi-

cine examinations require that data be

analyzed and presented in certain or-

mats, especially where fnal fgures are

produced e.g. ejection raction as a result o

gated cardiac wall motion studies (MUGA

scans). In most cases the analysis is objec-

tive, utilizing preset analysis programmes,

but some variations can be introduced in

their usage with reerence to positioning

o regions o interest. To minimize the sub-

jective eects o individual on the various

programs, protocols should be included

to give step-by-step guidance in their ac-

curate application.

Relevant papers copies o relevant arti-

cles, papers, monographs and manuactur-ers details are oten useul to include within

a protocol fle, or additional reerence and

constant updating o good practice.

A sample protocol is shown in Appendix 1.


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Gallium67 Whole Body Scans

Radiopharmaceutical: 110MBq Gallium-67 Citrate (one patient dose).

Radiologist should give injection.

Patient Preparation: Day 1 Ga67 injection given no scans.

Day 2 no scans. Patient should ast rom midnight, be givenbowel preparation or next day.

Day 3 (48 hours) Scan, patient to ast and be given urther

bowel prep

Day 4 (72 hours) Scan

Scan Delay: Scan on Day 3 (48 hours) and Day 4 (72 hours)

Scan Name: Ga67 wholebody scan (48hrs), Ga67 wholebody

scan (72 hrs), Ga67 planars (under Other on protocols list)

Scan Parameters:

Camera: Axis Dual-head

Isotope channel: Ga67 , 184, 296, and 388 keV, 10- 20% window widths

Collimators: MEGAP

Routine Views: Wholebody scan (anterior and posterior) + planars o areas o

interest i necessary at 48 Hours and 72 hours post-injection.

Due to low injected and retained activity, tomography is not

routine.Indications or Scanning: Non-specifc inection, inammation, PUO; tumors;

sarcoidosis

Display: As wholebody display, attach relevant static images. Label with

scan type and time (post injection) or each day.


Appendix 1: Sample protocol (Courtesy o St. Jamess Hospital, Dublin)


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Application o Departmental Policies

Policies are designed to be applied within

the Nuclear Medicine department as a whole,

rather than on an individual scan basis. The

policies generally are developed rom the

point o view o good practice, including

radiation protection, health and saety, and

inection control. All policies should be ap-

plied with the ull knowledge and co-opera-tion o all branches o personnel within the

department (nuclear medicine physician/ra-

diologist, physicists and radiographers/tech-

nologists) and should be made known to all

clinicians and departments making use o

the range o services oered by the Nuclear

Medicine department.

Radiation Protection Radiation dose to the patients as most

nuclear medicine procedures require an

injection o radioactive material attached

to a tracer, utmost care must be taken to

ensure that the correct procedure has

been selected to maximize diagnostic

suitability; that the radioactivity o the

injected dose ollows the principles o

ALARA (as low as reasonably achievable)

or ALARP (as low as reasonably practi-

cable); that the patient has been given

adequate inormation prior to the pro-

cedure and such atercare details as are

appropriate.

Protection with regard to a possible preg-

nancy the prime responsibility or iden-

tiying such patients lies with the reerring

clinician, but all personnel involved are

expected to actively ensure that radiation

is not used inappropriately with regard to

possible oetal irradiation.

All nuclear medicine procedures require

that precautions be taken when admin-

istering radioactive materials to emaleso child-bearing age. Details can be set

locally but with regard to nuclear medi-

cine procedures the 10-day Rule is most

oten applied. This requires that all ex-

aminations that include exposure o the

pelvic regions be deerred until the emale

is within the frst 10 days o the menstrual

cycle. Generally the only nuclear medicine

procedure that can be carried out duringpregnancy is an isotope lung perusion

study, and in many cases CT Pulmonary

Angiograms are perormed instead. The

European Commission provides practical

advice on the protection o pregnant pa-

tients and breasteeding mothers in the

guidance document Radiation Protection

100 Guidance or the protection o un-

born children and inants irradiated due

parental medical exposures, which avail-

able at the ollowing web address:

http://ec.europa.eu/energy/nuclear/

radioprotection/publication/doc/100_

en.pd


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Radiation protection o sta where a

patient is due to undergo a series o ex-

aminations on the same day, either in the

x-ray department or in other diagnostic

procedural units, these examinations

should preerably be perormed prior

to the nuclear medicine examination.

Where this is not possible e.g. during

breast surgery ollowing sentinel nodeimaging, protocols or such procedures

should have been confrmed in advance

and put in operation with the theater and

pathology sta concerned.

For inpatients undergoing a nuclear medi-

cine examination ollowing the injection

o radioactive material or when a nuclear

medicine procedure has been completed,an advice sheet is sent with the patient to

the ward regarding the type o procedure

undertaken, the radiopharmaceutical and

dose administered and the time or which

any restrictions apply.

Sample advice sheets are shown in

Appendix 2.



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DEPARTMENT OF NUCLEAR MEDICINE

ST.JAMESS HOSPITAL

Name o Patient: _______________________________________________________________

Consultant: ________________________ Ward: ______________________________________

Date: _____________________________ Time: ______________________________________

The above named patient has attended the Nuclear Medicine Department or the ollowing:

Scan Type: _________________________ Isotope: ____________________________________

Activity: ______________________________________________________________________

The ollowing precautions should be ollowed or a period o 24/48/72 hours (delete as necessary).

1. In general, try to avoid unnecessary close contact (less than 0.5m) with the patient.

2. Examination gloves and plastic aprons should be worn when handling urine bags, bottles, bedpans

and dirty linen. Any spillages should be cleaned up quickly and careully.

3. Soiled linen should be bagged and then stored or 24 hours beore being sent to the laundry.

4. Pregnant sta should minimise the time spent close to the patient and avoid close contact where

possible.

5. Pregnant visitors or small children should not be allowed to visit the patient or the period o theserestrictions.

6. Consider postponement o non-urgent investigations and treatments requiring sta working in

direct contact with the patient or more than 5 minutes.

7. Patient should drink plenty o uids and empty bladder requently.

SPECIAL PRECAUTIONS:

For urther inormation, please contact the Nuclear Medicine Department.

Appendix 2: Sample advice sheets (Courtesy o St. Jamess Hospital, Dublin)


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Guidance Notes or Nursing Sta Caring

or Nuclear Medicine Patients

Background

Patients attending or nuclear medicine scans

receive a pharmaceutical (usually although not

always by injection) that has been labelled with

a radioactive material. The pharmaceutical is

selected so that it is processed or metabolised

in the organ o the patients body that the clini-

cian wishes to assess. Ater the patient has been

injected he/she is eectively radioactive and

can act as a source o exposure to those with

whom they come into contact. Although this

exposure will be relatively low, in order to mi-

nimise sta exposure, some simple precautions

are advised and these are outlined below.

The isotope that is used most requently is

Technetium-99m (Tc-99m). This is a relatively

short-lived isotope with a hal-lie o approx.

6 hours. In eect, this means that precautions

generally only have to be ollowed or a period

o 24 hours ater the isotope scan. Occasion-

ally, other isotopes (e.g. Indium-111, Gallium-67,

Thalium-201, Iodine-123, Iodine-131) are used.Because some o these isotopes have longer

hal-lives than Tc-99m, precautions have to

be ollowed or a longer period. The time or

which precautions should be ollowed will be

indicated on the inormation sheet that is sent

back with the patient rom the Nuclear Medi-

cine Department

Guidance

The ollowing guidelines should be ollowed

or the period indicated on the instruction

sheet accompanying the patient back rom

the Nuclear Medicine Department:

1. In general, try to avoid unnecessary close

contact (less than 0.5m) with the patient.

2. Examination gloves and plastic aprons should

be worn when handling urine bags, bottles,

bedpans and dirty linen. Any spillages should

be cleaned up quickly and careully.

3. Soiled linen should be bagged and then

stored or 24 hours beore being sent to

the laundry.

4. Pregnant sta should minimise the time

spent close to the patient and avoid close

contact where possible.

5. Pregnant visitors or small children should

not be allowed to visit the patient or the

period o these restrictions.

6. Consider postponement o non-urgent in-

vestigations and treatments requiring sta

working in direct contact with the patient

or more than 5 minutes.

7. Patient should drink plenty o uids and

empty bladder requently.

For urther advice or inormation, please con-

tact the Nuclear Medicine Department.


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Health and Saety -

The health and saety o both sta and pa-

tients must always be placed frst in any con-

sideration o policies. Regrettably incidents

can occur within a department ranging rom

a change or deterioration o the patients

condition that requires advisement o nurs-

ing or medial support to accidental injury to

reactions to injected radiopharmaceuticals.Although the latter are relatively rare, they

are not unknown, and a policy and protocol

should be in place to ensure a record is made

o such incidents, and to register them with

the appropriate departments within the hos-

pital or with manuacturers. Most hospitals

have Risk Assessment teams that will log all in-

cidences and place them on permanent fle.

Inection Control -

Protocols regarding the operation o inec-

tion control procedures should be included

in departmental protocols. With the rise o

hospital-based inections such as MRSA and

C.Di., there is an increased need to be vigilant

in the prevention o cross-inection. Rigorous

cleansing regimes should be enorced when

known carriers o inections are scanned in the

Nuclear Medicine department, and protec-

tive clothing and equipment utilized. Similarly,

other pro-active steps e.g. usage o plastic pro-

tective sheeting on gamma cameras and scan-

ning tables should be used when an inectious

state cannot be ruled out.

The Nuclear Medicine department is also an

area o high risk when it comes to blood-borne

viruses, most especially HIV, because o blood-

labelling techniques utilized or certain exami-

nations. Sadly, instances where HIV inected

blood products were inadvertently injected

into the wrong patient have been recorded,

resulting in inection o the previously-HIV

negative patient. A report can ound at:http://www.cdc.gov/mmwr/preview/

mmwrhtml/00017383.htm

A proactive policy regarding the sae labelling

and introduction o labelled blood products

should be at the oreront o departmental

inection control procedures.

Similarly, a policy and protocol should be inplace to assist and record incidents involving

contamination o sta through needlestick

injuries. This should be co-ordinated with the

hospitals Occupational Health Department.


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Knowledge and compliance with the Good

Clinical Practice (GCP) is essential or ev-

eryone involved in clinical research trials.

Clinical trials should be carried out within

the ramework o a good clinical practice

environment in accordance with interna-

tional guidelines and regulations as detailed

in the Declaration o Helsinki. Research trials

involving ionising radiation require adher-ence to the ALARA (as low as reasonably

achievable) principle. The International

Commission o Radiological Protection

and the World Health Organisation (WHO)

have publications that deal with this issue in

clinical research. From the legislation point

o view, the 97/43/EURATOM Directive rep-

resents the most comprehensive reerence

to clinical research using ionising radiation.While GCP should orm the backbone to

successul nuclear medicine clinical stud-

ies, radiopharmaceuticals used in these trials

need to be produced according to the Good

Manuacturing Practice (GMP). Compliance

and understanding o the GCP is essential to

everyone involved in clinical research.

In an eort to overcome international GCP

inconsistencies throughout countries, the

International Conerence on Harmonisation

(ICH) published the ICH Guidelines: A num-

ber o components have been included to

ensure the protection o trial subjects and

the quality/integrity o data obtained rom

clinical testing.

Section 2 Guidelines / Policies / Protocols2.3. Clinical Research Policies

Linda Tutty

These are:

Institution review board (IRB)/indepen-

dent ethics committee (IEC) review and

approve;

The trial protocol;

Freely obtained inormed consent romeach subject;

Saety monitoring requirements;

Data handling and archiving require-

ments;

Clinical trial responsibilities o the IRB/IEC,

investigator and sponsor.

The IRB/IEC protects the rights, saety and well-

being o all trial subjects. The IRB/IEC should

examine the qualifcations o the investigator

or the proposed trial. It should carry out re-

views o each ongoing trial at intervals appro-

priate to the degree o risk to human subjects.

The IRB/IEC may request or additional inor-

mation be given to the subjects where that

inormation would add to the rights, saety

and/or well-being o the subjects. The IRB/IEC

should establish that the proposed protocol

and other documentation adequately address

relevant ethical concerns and meet applicable

regulatory requirements or trials.


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Accurate dosimetry

Clinical trials involving the use o ionising ra-

diation, as in the case o nuclear medicine,

require special consideration with regard to

the GCP. In addition to direct detrimental e-

ects, protection o humans against ionising

radiation requires consideration o the prob-

ability o induction o stochastic eects, such

as cancer and induction o leukaemia, even atlow doses. The beneft to society, by increase

in knowledge, must outweigh the potential

harm to the exposed individual. Such research

trials should only be perormed on a voluntary

basis as set out in the Declaration o Helsinki.

Dierent organisations have published speci-

ic recommendations with respect to research

using ionising radiation in medicine. The WHOpublished a report in 1977 concerning the

use o ionising radiation and radionuclides

on human subjects or areas including medi-

cal research. More recently the International

Commission on Radiological Protection (ICRP)

published a number o documents on the pro-

tection o patients with recommendations in

nuclear medicine, including exposure in bio-

medical research (Bacher & Thierens, 2005).

From the legislation perspective, in the EU,

the 97/43/EURATOM Directive represents the

reerence to clinical research using ionising

radiation (Bourguignon MH, 2000). In this

document the justifcation and optimisation

o exposure ollowing the ALARA principle

is crucial. With respect to optimisation, it is

important or accurate calculation o patient

radiation doses, and in the case o diagnostic

cases, to ensure that the radiation dose is as

low as possible. For therapeutic purposes, such

as radionuclide therapy, there is a requirement

or individual treatment planning by monitor-

ing the absorbed dose o the target volume

and by considering possible detriment o non-

target tissues. The eective dose may be usedas an overall indicator o the risk on late sto-

chastic eects to an average individual. Mean

organ doses and eective doses are typically

derived based on the data available in ICRP

publications 53, 62 and 80. I no established

biokinetic models exist or the applied radio-

labelled tracer, dosimetry may be based on

animal experiments which should be then

tested in pilot research on human subjectsbeore any extensive research is planned. For

radionuclide therapy investigations, where de-

terministic eects may occur, doses to critical

organs outside the target volume should be

examined accurately and individually or each

patient.

Good Manuacturing Guidelines

With the introduction o the European Direc-

tive, all pharmaceuticals used in clinical studies

must be prepared under good manuacturing

practice (GMP) conditions (De Vos et al, 2005).

Radiopharmaceuticals or clinical research pur-

poses must be manuactured in accordance

with the basic principles o GMP. Due to their

short hal-lives, many radiopharmaceuticals

are administered to patients shortly ater their


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1

production, so some elements o the quality

control may be retrospective. Thereore strict

adherence to GMP is essential. Special atten-

tion should be given to the production area

environment and personnel, the two basic

requirements o GMP production.

Radiopharmaceuticals are nearly always used

beore all quality control testing has beencompleted. Thereore the compliance with

the quality assurance programme is crucial.

Quality assurance should incorporate the

monitoring and validation o the production

process.

When conducting research trials in nuclear

medicine, special attention should be given

to the guidelines and legislation surround-ing GCP, radiation dosimetry and GMP. GCP

and the policies linked to it should be well

understood beore contemplating any clinical

research study in nuclear medicine.



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This Recruitment Chapter has been designed

to enable you to help carry out the recruit-

ment and selection process eectively.

The ollowing objectives should be achieved:

The right candidate should be recruited,

ensuring equality o opportunity or all

candidates and that there is the right can-didate or the right job in the right place.

The recruitment process should take place

in a timely and cost eective way.

Relevant legislation should be taken into

consideration.

The three stages in the recruitment processare:

Defning Requirements

Attracting Candidates

Selecting Candidates

Defning the requirements when the vacancy

occurs, the frst questions to ask will be:

Is there a vacancy?

I there is, who do we need to fll the post?

Sometimes it may be a case o reorganising

the work or using agency sta or making the

Section 3 Sta Aspects o Best Practice3.1. Best Practice or Recruitment and Selection

Wendy Gibbs and Julie Martin

job part-time or a job-share. We should al-

ways analyse the requirements at that mo-

ment in time as well as consider uture plans

and requirements.

In order to defne the requirements the ol-

lowing steps must be undertaken:

Job Analysis

Job Description

Personal Specifcation

Job Analysis

It is necessary to ask what the job consists

o and whether it is likely to be any dierent

than that o the previous postholder. NuclearMedicine covers many areas and the skills

required o a Nuclear Medicine Technologist

post will vary. It may be that a specialist such

as a Nuclear Cardiology Technologist is essen-

tial or a technologist who is newly qualifed,

to ensure that the right mix o sta is there

supporting the clinical work and providing

career progression.

Job Description (See Appendix 1)

The ollowing should be included:

The context o the post including respon-

sibilities and accountabilities

A small paragraph on the job summary


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The job content will include the main

duties and responsibilities to encompass

managerial, clinical, proessional & teach-

ing responsibilities and research & devel-

opment duties i appropriate

Personal Specifcation (See Appendix 2)

The personal specifcation should provide the

ollowing inormation:

Essential and desirable qualifcations

Knowledge and experience required to

undertake the job

Other inormation may be provided at this

point, such as working conditions, potential

career progression and in some cases peror-mance standards.

Advertising

The most cost eective and appropriate method

o recruitment should be selected. It is essential

the advertisement is placed where candidates

who are qualifed to take on the role are most

likely to look. In some cases this may mean adver-

tising internally only or internally and externally

simultaneously. This will depend on the market

orces and candidates available locally.

The ollowing is a checklist o items which

should be included in the advert:

Name & Brie details o employing organi-

zation

Job role and duties

Training to be provided

Key points o the personal specifcation

Salary

Instructions on how to apply

At this point the interview date may be set.

Shortlisting

Using the essential criteria in the personal

speciication, panel members individually

produce a list o applicants that meet the

criteria. They will be scored according to

criteria provided. The panel will then revealtheir lists and ind a consensus. Successul

candidates will then be invited or inter-

view.

Interviews or Nuclear Medicine Technolo-

gists will not generally involve a test, how-

ever it is suggested that in a senior role, a

presentation may be appropriate. Some or-

ganizations may use psychometric testing

as a matter o course.

Interviews: Points to remember

Legible notes to be written by each panel

member during the interview.

The same questions should be asked

apart rom speciics related to the CV and


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particular issues that may arise out o the

application orm and/or the interview.

Attention to any legislation such as the

(UK) Disability Discrimination Act should

be practiced.

Preparation is essential both by individu-

als and the panel. It is necessary to decidewho is chairing the interviews. In most

cases this will be the most senior per-

son. For a Technologists post it would be

appropriate to have the Senior or Chie

Technologist, Physicist or Radiopharma-

cist and/or a Medical Physician depending

on the seniority o the post.

The interview should start with introduc-tions and outline the interview process.

General biographical inormation would

be examined frst ollowed by examina-

tion o the application orm and compe-

tencies identifed or the job. The panel

will be listening and answering questions

and the chairperson closes the interview

by summarising and confrming uture

actions. He/she may be responsible or

checking qualifcations and details related

to occupational health and accommoda-

tion.

All panel members should be given a

copy o the interview plan beore the in-

terview.

Attention should be paid to the environ-

ment e.g. mobile phones switched o.

Ensure preparation is timely.

Dont leave candidate waiting and explain

any unoreseen delays.

Ensure proessional conduct at timesthroughout the process.

Upon completion o the interview, individual

members o the panel give their eedback

and agree on the appointment (or not) by

consensus.

Subject to the organisations policy, oers may

be made subject to; reerences, occupationalhealth clearance and/or Criminal Record

check.

A job oer will be sent out ormally and com-

mencement procedure and start date dis-

cussed.

APPENDIX 1

Sample Job Description

Post Title:Senior Nuclear Medicine

Technologist

Service: Nuclear Medicine

Hours o Work 37.5 hours

Reports to: Chie Technologist

Hospital / Organization Inormation

(small paragraph: 2-3 lines)


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Section 3 Staf Aspects o Best Practice

Nuclear Medicine Services

(small description 3-4 lines)

The Nuclear Medicine Department employs

sta and has an annual budget o . The

department undertakes general nuclear medi-

cine and osteoporosis screening. The depart-

ment has its own radiopharmacy and works

within the radiology unit.

Job summary

To provide high quality diagnostic images across

the range o all Nuclear Medicine investigations.

An understanding o the departmental protocols

is essential. Encouraging the highest proessional

and technical standards in all sta by personal

example and constructive supervision.

Main duties / key responsibilities1. Perorm all clinical nuclear medicine pro-

cedures using specialized equipment, in a

timely and accurate manner.

2. Perorm all diagnostic & therapeutic proce-

dures with due regard or Health & Saety

o sel, patients and sta.

3. Undertake administration o all diagnostic

radiopharmaceuticals and drugs used in

the practice o nuclear medicine.

4. Assist in cardiac exercise and pharmaco-

logical stress testing.

5. Schedule all nuclear medicine studies in

accordance with departmental protocol.

6. Take responsibility or patient consent,

identifcation and relevant clinical de-

tails.

7. Provide clinical inormation to the pa-

tient whilst interpreting, negotiating and

adapting the procedure as applicable to

that patient.

8. During exposure to sealed and unsealed

radioactive material, blood samples and

other hazardous waste, ensure working

practice is in accordance with govern-

ment legislation and departmental poli-

cies.

9. Understand and apply all relevant legisla-

tion when perorming all nuclear medi-cine investigations.

10. Undertake quality assurance o all rel-

evant equipment and take responsibility

or reporting discrepancies to appropriate

personnel.

11. Participate in research and development

studies being carried out in the depart-

ment.

12. Take responsibility or continuing proes-

sional development while liaising with

the line manager or advice, guidance

and allocation o appropriate resources

or training and development.


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Standard Requirements

The post holder may be required to carry out

other duties in line with the grading o the

post.The job description may be subject to

change and i so this will take place in con-

sultation with the post holder.

The ollowing policies should be adhered to

at all times as per induction: Confdentiality,Code o Conduct, Equal Opportunities, Health

and Saety, Smoking Policy, Data Protection

Act, Terms and Conditions o Employment.

APPENDIX 2

Sample Person Specifcation

Person Specifcation

Senior Nuclear Medicine Technologist

Qualifcations

Essential: BSC Radiography or other relevant

science degree with a post gradu-

ate qualifcation in nuclear medi-

cine or Nuclear Medicine Degree

(BSc Applied Science in Nuclear

Medicine Imaging)

Desirable: Paediatric IV cannulation course

ILS or ALS certifcate

Basic and advanced ECG inter-

pretation

EANM PET course or equivalent

CT accreditation

Knowledge & Experience

Scientifc, Technical & Clinical

Minimum 5 year ull-time experience post

qualifcation.

Competent in all nuclear medicine proce-

dures.

Demonstrate an ability to work within amulti-disciplinary team.

Competent in all data acquisition and

analysis or nuclear medicine procedures.

Able to recognise normal and abnormal

bio distribution o radiopharmaceuticals.

Provide a high quality proessional stan-dard o care to both patients and sta.

Legislation: Understand and comply with

relevant legislation, national standards, and

proessional guidelines.

Skills:

IT: Proven IT skills to intermediate level on MS

Oce & Outlook.

Communication: Developed skills required

to work with patients and

sta rom diverse back-

grounds. Capable o ex-

tracting/imparting sensi-

tive inormation.


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Section 3 Sta Aspects o Best Practice3.2. Best Practice or Induction

Wendy Gibbs and Julie Martin

Providing an eective and thorough induction

ensures new starters are settled quickly into

their new working environment. It is about

presenting the basics that experienced em-

ployees take or granted.

A good integration into the working environ-

ment must include the ollowing elements:

General training relating to the organiza-

tion, including values and philosophy as

well as structure and history, organizational

charts etc. (see appendix 1)

Mandatory training relating to health and

saety and other essential or legal areas.

Job training relating to the role the newstarter will be perorming.

Training evaluation, entailing confrma-

tion o understanding, and eedback about

the quality o and response to the training.

It is the responsibility o a new employees

manager to ensure that induction training is

properly planned. An induction plan should

be issued to the new employee on their frst

working day i not beore and sent to all sta

involved with the training. Although an induc-

tion period should be specifed, there is no

right induction time or new employees. In

some instances an induction can span over a

ew months. In these cases it is important or

the new employee that the induction does

not lose momentum and that s/he has pro-

tected time to undertake and complete the

induction period.

Induction is a two-way process. The manager

is responsible or ensuring:

That the inormation, explanation, guid-

ance and direction needed is providedwithin the induction plan.

That mandatory training required has been

booked e.g. Basic lie support, fre training

etc.

That the new employee has the opportu-

nity to ask questions and seek guidance.

That the new employee is eectively in-

ducted into their job and competent to

undertake the necessary tasks saely.

That a checklist or induction is provided

to ensure all areas are completed (see ap-

pendix 2) and sign o as completed (see

appendix 3).

The new recruit is responsible or:

Reading and absorbing all inormation pro-

vided throughout the induction period.

Attending any training provided and re-

quired as part o the job.


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9


Asking questions and seeking guidance

where help or clarity is needed.

Completing and making the most out o

the planned induction.

APPENDIX 1

Organisational Chart

The ollowing checklists have been provided as

a guide (and are by no means all encompass-

ing) to help acilitate the induction process.


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0

APPENDIX 2

Induction Checklist

Employee Name: ____________________________________________________________

To be achieved within the frst week o startingTick as appropriate

Done N/A

I have been introduced to my Personnel Team

I have signed my joining papers (or payroll)

I have been given the opportunity to have an induction buddy

I have discussed the job description and person specifcation and

understand the purpose o my job

I have been ormally introduced to:

Other members o my team/dept

Head o Nuclear Medicine Service Manager

Lead Clinician or Nuclear Medicine

Other Consultant Colleagues within dept

Key Clinical Sta (list sta)

Key Consultant Colleagues outside o dept

Key Management Sta (list sta)

Divisional Management Team

I have been shown:

The layout o the department

Any areas I will be working in outside my department/ward


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1

Fire escapes, the location o fre alarm points and the fre assembly

point

Toilets/cloakroom/rest room acilities

Area to store and make rereshments

Sta dining acilities

Telephone acilities

Bleep system

The location o the frst aid box

The location o the resuscitation equipment

The photocopying acilities

The location o linen room

The equipment I will be using - computer, medical equipment etc.

The location o the post room

The location o the security oce

I have been advised o:

The cardiac arrest number

The fre & emergency security number

I have been provided with:

Uniorms

Facilities to lock away my personal belongings

A current copy o the organisations Newsletter/Team Briefng

Reports

A copy o the Sta Handbook and sta policies summary



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A copy o the Organisations Code o Conduct

An ID Security Badge/Access Swipe Card

Training: I have been given a date to attend:

Fire training

Training in basic lie support resuscitation

Training in paediatric lie support resuscitation

Manual handling training

The corporate induction programme

Child protection training

Training to receive organisations IT system/s

Proession-specifc induction (i provided)

Local induction programme (i provided)

I have been made aware o the ollowing policies/procedures:

Hours o work, rotas, breaks

Salary payment procedures

Sickness reporting procedures, sick pay entitlement and medical

certifcate requirements

Annual leave entitlement and booking procedure

Policies and procedures manuals

Fire alarm and fre drill procedure

Data Protection Act and the importance o data quality

Resuscitation guidelines


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Risk management guidelines

Health risks and saety procedures including protective clothing

Personal/patient security

Medicines policy

New patient records policy

Raising a matter o concern policy

Adverse incident reporting

Compliments & complaints policy

Waste disposal procedure/policy including types o bags

Patient care philosophy

Inection control & hand washing

Standard Operating Procedures/ Service Level Agreements (SOPs/

SLAs as required)

Confdentiality

Regulatory policies aecting working area

Any other procedures relevant to the area o work (please list):

To be achieved within two weeks o startingI have been made aware o the ollowing policies/procedures/

protocols:

Access to medical records

Equal opportunities policy

Waste disposal policy

Trust email and internet policy



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Sta benefts/acilities e.g. crche, sta clubs, ftness centres

Media policy

Learning & development ramework

Major incident plan

To be achieved within frst month o starting

I have been made aware o the ollowing:

My organizations & team objectives

The Trusts Perormance Management Process

To be achieved within 3 months o starting

I have a date when I will meet with my line manager to plan my

perormance and development objectives

I have received a contract o employment


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APPENDIX 3

Sign o sheet

INDUCTION REVIEW FORM

Evidence o Induction Process

Name: __________________________ Post: _____________________________________

Start Date: _______________________ Department: ______________________________

Induction completed: _______________________________________________________

Employees comments:

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

Managers comments:

_________________________________________________________________________

_________________________________________________________________________

_________________

Tech Best Practice

Documents