Standard of Care. Standard of Care: Defining Documents. Additional Sources. Objectives By the end of this presentation, attendees should be able to:

Transcription

1 Objectives By the end of this presentation, attendees should be able to: 1. Explain the standard of care in medical imaging and identify source documents. 2. Explain the technologist s duty and ethical obligation to protect patients from harm. 3. Define negligence as it pertains to the imaging environment. Prepared and presented by: Thomas G. Sandridge, M.S., M.Ed., R.T.(R) Program Director Northwestern Memorial Hospital School of Radiography Chicago, IL Thomas.Sandridge@nm.org 4. Identify intrinsic and extrinsic factors placing patients at elevated falls risk. 5. List falls risk factors that can be readily assessed by imaging technologists. 6. Perform a falls risk assessment on imaging patients. 1 2 Standard of Care Reasonably Prudent (Technologist) Standard: o all members of a profession o knowledge, skill and ability o There is only one standard of care for the profession! Deviation from the Standard of Care: o Negligence Unintentional tort Malpractice cases Expert witnesses 3 4 Standard of Care: Defining Documents Additional Sources American Society of Radiologic Technologists (ASRT) ASRT Code of Ethics ASRT Practice Standards* (for each modality) ASRT Curriculum (for each modality) ASRT Position Statements ASRT Advisory Opinion Statements American Registry of Radiologic Technologists (ARRT) ARRT Standards of Ethics (and Rules) Available literature ACR publications Textbooks 5 6 1

2 Defining Documents: ASRT Code of Ethics Ethical Principle 1 5 Obligation Professional conduct Provide quality patient care Patient assessment Discretion and judgment (critical-thinking skills) Accountability for your actions Act in the best interest of the patient 7 Perform according to an acceptable standard of practice 8 Ethical conduct Protect patient s right to quality care 7 8 Defining Documents: ASRT Practice Standards Defining Documents: ASRT Curriculum Guide for appropriate practice Defines the profession and establishes criteria Designed to ensure that entry-level practitioners possess the skills outlined in the ASRT Practice Standards. Blueprint for educators to follow Authoritative statements Published for each modality Available on the ASRT website 9 Available on the ASRT website 10 Defining Documents: ASRT Position Statements Defining Documents: ARRT Standards of Ethics Beliefs or positions of the ASRT on various practice-related issues Technologists must also take into account: o State statutes o Institutional policies Part 1: Code of Ethics Part 2: Rules of Ethics Mandatory standards Enforceable Violators subject to sanctions o Radiologist preferences Available on the ASRT website

3 Negligence Falls-Related Deaths, Age 65+ Failure to take the care that a responsible person usually takes; lack of normal care or attention. Merriam-Webster Dictionary Negligence is the failure to use reasonable care: Act of omission Act of commission Reasonably Prudent Standard 13 Source: Statistical Abstract of the United States 14 Falls Risk Assessment: The Why Each year: 1/3 of elderly in the U.S. fall 2.5 million are treated in the ED: 700,000 + hospitalized for fractures or brain injuries More than 250,000 for hip fractures (75% are women) Annually, the following proportion of the elderly population falls: Group: Percentage: > 65 years 28 35% > 75 years 32 45% Institutional care > 50% Recurrent fallers* 60 70% Falls in the Elderly Leading cause of fatal injuries 20 30% of falls result in moderate-to-severe injuries: o Fractures: hip and extremities o Traumatic brain injuries Fear of Falling & Post-Fall Syndrome Annual Cost of Elderly Falls Average cost per fall: $35,000 Costs increase with age Direct medical costs: $34 billion Estimated $67.7 billion by

4 Center of Gravity Factors Influencing Balance & Gait Point where the mass of the body is concentrated Typically at the level of S-2 Stability: Center of gravity is directly over the base of support (next slide) Center of Gravity Base of Support Kyphosis and Balance Line of Gravity Line of Gravity Center of Gravity Base of Support Ankle Joint Axis Center of Gravity Foundation: Wider base = better balance 21 Base of Support Base of Support 22 Extrinsic (Environmental) Factors Includes: Poor lighting Stairs: steep, inadequate rails Low doorways Clothing and footwear Elevated Risk Factors Lack of assistive devices (when needed) Throw rugs, clutter Uneven pavement

5 Intrinsic Factors Age Risk increases with age Visual & Contrast Acuity Age-related loss Impaired Hearing Slower Motor Reaction Time Cognitive Issues Dementia Insufficient sleep Intrinsic Factors (continued) Balance and gait issues Medications and alcohol: Polypharmacy Abuse Cardiovascular problems: Postural hypotension Syncope Arrhythmias Prior CVA Urinary incontinence Muscle weakness Vitamin D deficiency Lower extremity deformities Previous Falls Intrinsic Factors: Foot and Ankle Deformities Altered base of support Congenital deformities: Club foot Other conditions Pathological deformities: Arthritic changes Bunions Hammer toes Corns and calluses Plantar fasciitis and heel spurs Intrinsic Factors (Continued) Obesity Obese patients have reduced balance recovery abilities Increased sway when walking: o mass movement of inertia about the ankles o risk of balance loss and falls o More sway = greater risk of falling Intrinsic Factors (continued) Underestimating risk Use of assistive device Postural issues: Kyphosis Inactivity and muscle weakness Performing a Falls Risk Assessment in Radiology

6 What is a falls risk assessment? Formal or informal evaluation To identify: environmental and / or personal risks Formulate appropriate action plan 2 or more risk factors = elevated risk Radiology Patients Limited time to assess Often unfamiliar with the patient s history HIPAA restrictions Easy-to-spot red flags Never simply ask the patient if they can stand and rely on their answer Look for red flags Remember: patients may overestimate their abilities Muscle Strength Gait-Related Issues Greeting the patient: How easily can the patient rise from a seated position? Red flags: Unable to stand Slow to rise Require assistance Walker or cane Postural hypotension Stride velocity: Slower or faster? Stride length: Consistent and longer, or shorter / inconsistent? Neurological conditions impacting gait Clothing and Footwear Loose clothing Improperly-fitting shoes Untied shoe laces, trip hazard Wearing socks (only) If the gown touches the floor, or is close to touching: Creates a trip hazard Take preemptive action: Tuck gown into patient pockets if wearing pants Tie up the bottoms of the gown (lift and tie together) Try to find a shorter gown

7 Previous Falls and Fractures Indicative of an elevated risk Ask the patient: Why or when did you start using a walker or cane? If you notice limited range of motion such as an arm, ask about it. If it is a follow-up exam, find out the original cause of injury. Breathing Issues Is the patient experiencing shortness of breath? COPD Asthma Bronchitis Pneumonia CHF Reduced oxygen level in circulating blood May cause heart rhythm changes and syncope Scenario: What would you do? Mary is 82 years old and scheduled for a shoulder x-ray. She has a history of rheumatoid arthritis resulting in an ankle deformity. She is osteoporotic, severely kyphotic, and walks with a wheeled walker. The technologist greets her in the waiting room and notices her difficulty standing from the chair. As they walk to the exam room, the technologist notices how slowly she is walking and her ankle deformity. The technologist helps the patient change into a gown. Because of her kyphosis, the gown is touching the floor. When asked if she could stand for the procedure, the patient said yes A Quick Recap: Red Flags Rely on visual and auditory cues Older age Visual / hearing impairments? Altered mental status Ability to stand up: Light headed / weakness Assistive devices (walker/cane)? Gait: Pace and stride length / speed Level of control / balance Obese, gait sway Postural issues / kyphosis? SOB? Fall history? Lower limb deformities? Known history of RA? Gown length Shoes tied, fit? end

8 Case #1: Mary (from the scenario) Facts of the case Mammogram - can be done standing or seated. 9 identified risk factors plus recovering from a fractured right shoulder with limited ROM (risk factor #10). Tech decided to perform the exam standing. Case #1: Mary Patient Impact Hospitalized for ORIF Rehabilitation facility Physical therapy Multiple physician visits Limited mobility other medical issues $$$$ Case #2: Barbara Facts of the case 58 year old, advanced MS Wheelchair bound since 2005 Pre-operative chest x-ray (cataract surgery) Technologist had husband transfer her onto a wheeled stool without back support (12 inches higher than wheelchair seat). PA exposure made, patient slides off. Has husband put her back on the stool for lateral. Slides off again, landing on both knees. Bilateral fractures, distal femur Case #3: Sarah Newest Case (Still in discovery) 84 year old female Orthopedic practice Fell 2 months prior, follow up x-ray for shoulder fracture Felt weak, needed to sit Wheeled stool, no locks Tried to get up and fell Fractured femur Conclusion Patient assessment is a critical part of the Standard of Care. We also have an ethical obligation to protect patients from unnecessary harm. There are easy-to-identify factors that a patient is an elevated risk; don t ignore them. Don t rely solely on the patient s assessment of their abilities. 47 8

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