Table 1

Key drivers with their specific interventions

Key driversInterventions
(A) Promotion of safe radiation practices
(1) Procedure related
  1. Radiographers were educated on three radiation surrogates necessary to assessing procedural radiation exposure: fluoroscopy time (FT), dose area product (DAP) and air kerma. A separate paediatric radiation register was also maintained for recording these values.

  2. Low radiation protocol such as low frame rates, stored fluoroscopy options, avoiding magnification and the use of filters was encouraged. Repeated monitoring, immediate feedback and continual reinforcement of practices were implemented.

  3. Mandatory use of dosimeter badges for all staff involved in catheterisation procedures with check-ups every 3 months for radiation exposure (in millisieverts (mSv)) was enforced.

(2) Staff related
  1. Use of appropriate protective gear was mandated and biannual checks for cracks and contamination were performed.

  2. Use of lead glasses, especially by primary operator, was encouraged.

  3. Radiation best practice signs were posted in the catheterisation lab.

(B) Adequate staff education
  1. Serial lectures to improve knowledge regarding cardiac haemodynamics, calculations, CHARM risk stratification and adverse events were initiated for all CCL staff. This was done with the objective of raising staff awareness of patient status, recognising adverse event risk and detecting the beginnings of an adverse event to enable timely response.

  2. Regular precatheterisation case discussions were initiated which included all the CCL staff (nurses, technicians, fellows, faculty, and so on). The purpose was to increase interest and engagement of the staff during the procedure. This case discussion was brief and covered the diagnosis, the purpose of the procedure, the risk category of the procedure, haemodynamics to expect, haemodynamic calculations and, for interventional cases, a discussion of inventory and intervention sequence. The meeting ended with staff assignment of roles and responsibilities during the case.

  3. Staff engagement and interest were appreciated after procedure.

  4. The CCL staff was mandated to attend sedation and radiation protection workshops.

  5. All CCL staff members were involved in quality improvement projects in the lab.

(C) Documentation optimisation
  1. Catheterisation reports were standardised and all variables needed for C3PO-QI were captured. Documentation was deemed inadequate (as described in table 2) if information was missing without a clear explanation. Immediate feedback was provided to the primary and secondary operators regarding inadequate documentation. Addition of PaO2 of oxygen for haemodynamic calculation was made essential during hyperoxia tests.

  2. A poster displaying pictures of procedural efficacy of the five interventions (patent ductus arteriosus (PDA), atrial septal defect (ASD) closure, pulmonary and aortic valvuloplasties and coarctation of aorta (CoA) stenting) was placed in the CCL. This was done to standardise procedural efficacy documentation immediately during the case thus decreasing likelihood of any recall bias.

(D) Sustainability of standard practices1. A quality improvement team was formed including a head nurse, a radiographer, an interventional cardiologist, a cardiology fellow and the service chief. This team was established to perform monthly audits in order to determine: the adequacy of documentation, effectiveness of morbidity and mortality meetings, and staff radiation exposure using dosimetry batch data. The team also performed quarterly comparative analyses of AKUH versus cumulative C3PO-QI data and biannually determined the adequacy of radiation protection gear. This team was also tasked with preparing quarterly reports on the CCL quality metrics sharing the reports with the staff.
  • AKUH, Aga Khan University Hospital; CCL, cardiac catheterisation laboratory; CHARM, Catheterization for Congenital Heart Disease Adjustment for Risk Method; C3PO-QI, Congenital Cardiac Catheterization Project on Outcomes-Quality Improvement.