Rotation: NUCLEAR CARDIOLOGY AT VHVI AND VUH NUCLEAR MEDICINE

Transcription

1 Rotation: NUCLEAR CARDIOLOGY AT VHVI AND VUH NUCLEAR MEDICINE or: Marvin Kronenberg, M.D. Faculty: Michael Baker, M.D., Geoffrey Chidsey, M.D., Andre Churchwell, M.D., Keith Churchwell, M.D., Julie Damp, M.D., Thomas Richardson, M.D., Rob Hood, M.D., Mark Lawson, M.D., Dominique Delbeke, M.D., Ph.D., William Martin, M.D., Ronald Walker, M.D., Laurie Jones-Jackson, M.D., Learning s Patient Care Obtain pertinent medical histories by review of patient medical records. Screen patients for suitability for stress testing, including the performance of focused physical examinations to aid in screening and establish safety of stress testing, plus to detect contraindications to stress testing, either by exercise or pharmacologic methods. Learn methods for interpretation of tests and risk stratification. Produce high quality reports that adhere to American Heart Association and American Society of Nuclear Cardiology standards, and suitable for inclusion in the Vanderbilt electronic medical record. Be able to integrate test results in the context of patient management. Feedback Feedback observation, performance ratings, observation, performance ratings, Medical Knowledge Preceding this rotation, the fellow or resident should be qualified in advanced cardiac life support. Understand indications, methods, risks and benefits of stress testing, using both exercise and pharmacological Didactics

2 methods. Text reading Understand basic principles of radiation, radiation dosimetry, radiation protection. Know the basic properties of the commonly used radioisotopes, Tc- 99m and Tl-201. Understand the basic principles of gamma cameras, image acquisition and image processing of myocardial perfusion scans and radionuclide ventriculography (equilibrium gated radionuclide angiography). Understand pathophysiology of myocardial ischemia and infarction, plus the elements of how to evaluate ventricular performance, both regional and global. Understand the basic image characteristics of myocardial ischemia and infarction, and their effects on perfusion imaging. Recognize common imaging artifacts and become facile in their detection. Understand methods of attenuation correction, strengths and weaknesses. Become expert in performing both exercise and pharmacologic stress testing, including arrhythmia interpretation and ECG stress test interpretation. Understand how to integrate myocardial perfusion scan results with clinical and ECG parts of stress testing. Literature: read completely a standard textbook chapter on nuclear cardiology, and read guidelines for cardiac stress testing and nuclear stress test reporting. Professionalism Maintain patient privacy

3 Be accessible to colleagues Be personally responsible for actions. Demonstrate compassion and respect for others, including patients from a diverse cultural, social, and religious backgrounds, Feedback from staff Interpersonal and Communication Skills Communicate effectively with patients, families, and members of the health care team, including findings and diagnoses when appropriate to both patients and consulting physicians. Communicate abnormal results to ordering physicaians timely. Maintain timely and comprehensive medical records, including the prompt generation of standard nuclear and ECG stress test reports that will be available same day in the electronic medical record., Feedback Practice Based Learning and Improvement Identify both strengths and gaps in knowledge and expertise and set appropriate learning goals observation,

4 Utilize information technology to effectively locate, appraise, and utilize evidence based medicine in current literature to answer clinical and technical questions Respond appropriately to feedback and accept constructive criticism Utilize quality improvement methods to implement changes within the practice environment Feedback, Feedback, Feedback, observation, observation, Systems Based Practice Work effectively as a member of the health care team Demonstrate understanding of cost-effectiveness and risk-benefit analysis Advocate for and work towards patient safety and improved quality of care Identify system errors and implement systems solutions Feedback Rotation Format and Responsibilities:

5 General Description The Division of Cardiovascular Medicine offers training in cardiovascular nuclear medicine in coordination with the Division of Nuclear Medicine, Department of Radiology and Radiological Sciences. The training program emphasizes hands on training in stress testing, plus interpretation of cardiac imaging done by conventional perfusion imaging, positron emission tomography, and gated cardiac blood pool imaging (radionuclide ventriculography, equilibrium gated radionuclide angiography). We do this training in close cooperation. The ACGME recognizes three levels of training, an introductory experience (Level I) which all fellows should fulfill, a more in-depth experience (Level II) which will allow us to recommend a fellow as competent to perform and interpret procedures and to be certified by the Nuclear Regulatory Commission to join the broad scope license of an institution or establish an office-based freestanding laboratory, and a comprehensive experience (Level III).which will allow a fellow to do the above and have the competence to run a nuclear cardiology laboratory and establish a research program. These levels of training are documented in detail in the COCATS recommendations for training in adult cardiovascular medicine (J Am Coll Cardiol 2008;51: ; Other sources are listed in the document below: Nuclear Cardiology Service,, which was authored by our colleague, William H. Martin, M.D., or of the Nuclear Medicine Residency Training Program in the Department of Radiology and Radiologic Sciences. The Department gives a 7-month course entitled, Diagnostic Radiology Imaging Physics. This comprehensive review will fulfill the need of trainees to obtain the basic science experience essential for certification by the Nuclear Regulatory Commission and the Certification Board of the American Society of Nuclear Cardiology. Training in Vanderbilt Heart and Vascular Institute Fellows rotate on the Imaging Service for 28 day periods in which they are responsible for interpretation of nuclear cardiology procedures, including stress tests with perfusion scanning, and resting radionuclide ventriculography, in addition to cardiac magnetic resonance imaging, which will be discussed separately. The fellow is responsible for being available to solve problems related to nuclear stress testing, in consultation with the nurses who perform the tests. After tests are completed, the fellow is responsible for a preliminary interpretation of the baseline ECG, the stress ECG and the nuclear perfusion scan. Then, each test is reviewed with the faculty member assigned for reporting the results. Positive results are communicated personally to the ordering physician. All test results are processed using our electronic reporting system on a same day basis. In addition to the clinical reporting experience, each fellow is expected to read the cardiovascular nuclear medicine section of a standard cardiology text, and to supplement this knowledge with specific literature as needs arise. Further, each fellow is expected to attend the Catheterization-Computed Tomography-Nuclear Correlative Imaging Conference, presently held each Wednesday 7:00 AM in MCN-111, and to attend the monthly Nuclear Cardiology Journal Club, which meets in the VUH PET conference room. The first and second year fellows are responsible for presenting journal articles at this conference, with the object of comprehensive discussion and analysis of the topic selected. The second year fellows will do these presentations for the first 6 months of the academic year, and the first year fellows and nuclear medicine residents will be responsible for the second half of the academic year. The comprehensive presentations will include Power Point slides illustrating the article, plus a comprehensive analysis of the quality of the article and the literature to put it in perspective. Nuclear Medicine and Cardiology faculty will attend and facilitate the discussion.

6 Training in Cardiovascular Nuclear Medicine, Vanderbilt Hospital Fellows will obtain a comprehensive experience in hands-on stress testing, including decisions on performing stress testing, methods for exercise and pharmacologic stress testing, and interpretation of myocardial perfusion scans and radionuclide ventriculography. Fellows will be exposed daily to conventional perfusion scanning using 99m Tc labeled drugs, positron emission computed tomographic imaging using 82 Rb, and, intermittently to emerging technology. The following is from the Nuclear Cardiology Service Manual, written by Dr. Bill Martin. 1. Welcome to the VUH Nuclear Cardiology Service; you are a part of a dynamic collegial team approach to cardiac imaging. While patients are in our department, they are solely our responsibility. 2. Your evaluation will be 360 degrees including feedback from faculty, technologists, nurses, tech students, and residents. Your performance at conferences and journal club will be a part of that evaluation. 3. You are responsible for the interpretation of all cardiac SPECT, cardiac PET, and RVG studies performed in the department. On Mondays, you will also have the experience of interpreting all of the SPECT and RVG studies done at the Heart Institute; we also interpret them on the 1 st, 3 rd, and 5 th Thursdays each month. On Wed, Dr. Kronenberg interprets all inpatient SPECT and all PET studies. On Fridays, Dr. Kronenberg interprets all cardiac PET studies. 4. Physicians-in-training are expected to be familiar with the indications and contraindications of the various stress/imaging protocols within the first 1-2 days of training. See the ACC/AHA and ASNC guidelines and your textbook. The attending of the day is always available for consultation. 5. The day begins at 8 a.m. (or before) with screening of scheduled patients for appropriateness and type of stress. Consider switch to Rb PET for obese patients, women with breast prostheses, or those who had equivocal SPECT in the past. Always try to combine low-level exercise with adenosine or Lexiscan (regadenoson) if possible. Please screen inpatients as soon as possible as they are added on. The requesting physician should be consulted before the requested protocol is altered. If there are scheduling problems with add-ons/cancellations that you are unable to resolve, call the nuclear medicine attending physician. No study can be canceled without agreement from the referring ATTENDING physician. At VUH, low-dose CT attenuation correction is always performed except with the D-SPECT instrument; prone imaging is used as deemed appropriate 6. A schedule for the performance and interpretation of regular-hours, after-hours, and weekend cardiac SPECT s and PETs should be arranged amongst the fellows and residents and provided to the technologists and attending staff at the first of the month. If the scheduled physician is unable to provide efficient service to the patient because of clinical or educational scheduling conflicts, it is his/her responsibility to arrange alternative coverage, if even for an hour, notifying the nurses AND the techs of the alternative coverage.

7 You are encouraged to attend educational conferences and physics lectures but communication with the techs and nurses is mandatory 7. Physicians (in-training and faculty) are expected to respond to pages from the technologist(s) within 1-5 minutes. Our goal is to provide an efficient service to the patients and to the requesting physicians Patients should not be kept waiting. There is often another patient waiting to be stressed or scanned; delays create problems. ED patients receive priority for stress performance and interpretation. You are expected to know the patient before you walk into the stress room The PET schedule is very tight; Rb patients should be stressed in a timely manner As necessary, nuclear medicine residents AND faculty are happy to assist in stressing patients, etc. Just ask. ED patients and inpatients not put into the system prior to 4:30 are stressed the following day. 8. The technologists and nurses are an equal and integral part of our team and have a multitude of responsibilities. The physician is responsible for all clinical duties including initial assessment, EKG interpretation, stressing the patient, monitoring vital signs and rhythm, and providing post-stress care. You are solely responsible for watching that monitor. The heart station worksheets should be completed electronically by the physician stressing the patients; the nurses will complete as much of it as they can. Hit SAVE at the end not Archive. The ECG strips are transmitted electronically to the heart station for formal interpretation. It is useful to print the sheet after it is completed so other physicians may communicate with physicians who may call for results. 9. If any patient experiences complications during a study (arrhythmia, ST elevation, prolonged chest pain, etc.), contact the referring physician regarding triage. 10. After review with the attending physician, all studies should be dictated on the day of the study, even if delayed 24-hour imaging is planned. Physicians-in-training are expected to know the patient s history, the prior ECG findings and the prior scintigraphic and cath findings prior to stressing the patient and at the time of interpretation, including VHVI patients. The attending clinician should be notified by telephone of the results of all abnormal results. Studies are interpreted throughout the day, and faculty are usually available by page as studies appear. 11. ED patient interpretations are dictated in stat status, and are both called to the ATTENDING ED physician as well as iboxed on PACS; very important that the information in the ibox and on the final report are identical (Scan,, ECG, EF, CT). 12. All verbal communication of results should be documented in your dictation on this rotation and throughout your career. 13. All perfusion and RVG studies, including those performed at VHI, should be compared and correlated with any prior studies.

8 14. For the VHI studies: requisitions with Accession nos as well as a schedule are faxed to the reading room each morning. In the morning, the patients should be reviewed on StarPanel for prior studies and pertinent history. The stress reports are available on the PC. 15. Review of your dictated reports prior to editing by the attending is recommended as an educational exercise. Your goal is a perfect report that does not require any edits. 16. It is the responsibility of the physicians covering the VUMC nuclear cardiology service to assist with coverage for the VAMC nuclear cardiology service when requested by the VAMC staff. 17. All in-training physicians are expected to have hands-on experience with preparation and administration of 18 FDG, 99m Tc-sestamibi, 99m Tc-tetrofosmin, 201 Thallium,adenosine, dipyridamole, regadenoson and dobutamine as well as the glucose loading procedure for 18 FDG patients. Sign-off sheets will be reviewed at the end of the year. 18. All physicians in-training are expected to be able to process SPECT and RVG data by the end of their second month of training. Sign-off sheets for cardiac procedures and radiopharmacy will be reviewed at the end of the year. 19. Each physician-in-training is expected to keep a log of the procedures he/she participated in. 20. Weekly multimodality imaging conference each 7 am Wed is mandatory for all physicians-in-training on the nuclear cardiology service. It is the responsibility of the nuclear cardiology physicians-in-training to present 3 cases at this conference every 3 rd Wed. Faculty or NM residents can assist in preparation. 21. Joint radiology/cardiovascular medicine nuclear cardiology noon conference is every 1st Friday in MCN. 22. Monthly nuclear cardiology journal club is at 8 a.m. every 4 th or 5 th Friday and is mandatory. (PET Conference room) A critical PP Presentation of a recent important journal article from J Nucl Med, Circulation, JACC, AJC, J Nucl Cardiol, NEJM, Eur J Nucl Med, etc. Fellows on the Imaging rotation at VVHI are expected to collaborate with this endeavor. 23. Fellows and residents are invited to attend the nuclear medicine technology lectures daily; a schedule can be obtained from Dr. Patton s office (2-0508). 24. Membership in the American Society of Nuclear Cardiology is encouraged. The address: ASNC, 9111 Old Georgetown Rd., Bethesda, MD, ; ; (fax). admin@asnc.org. 25. Required reading: a) ACC/AHA and ASNC guidelines (1 st week of 1 st rotation). b) Guidelines for Performing Stress Cardiac SPECT and the rest of this manual c) Cardiac chapter in Mettler FA, Essentials of Nuclear Medicine Imaging or Requisites of Nuclear Medicine. d) Cardiac chapter in Habibian R, et al., Nuclear Medicine Imaging, A File, Williams & Wilkins-Lippincott, Inc., 2 nd Ed, Recommended selected readings:

9 a) Germano G and Berman DS. Gated Cardiac SPEC T, Futura Publishing Co, 1999, especially Chapter 6 (Artifacts Clarified by and Caused by Gated Myocardial Perfusion SPECT), Chapter 7 ( Value of Combined Perfusion and Function Imaging in the Diagnosis, Prognosis, and Management of Patients with Suspected or Known CAD), and Chapter 8 ( of Myocardial Perfusion and Left Ventricular Function in Acute Coronary Syndromes, Implications for Gated SPECT Imaging). b) Vitola and Delbeke. Nuclear Cardiology & Correlative Imaging, 2004; selected chapters. c) Numerous other nuclear cardiology text books have similar chapters. 27. research opportunities are available and can be arranged via any of the nuclear cardiology attending staff. William H. Martin, M.D. Revised 1/6/09 Requirements for Certification (for lab rotations): William Martin, M.D. and Marvin Kronenberg, M.D. Second and third year fellows are expected to be role models for first year fellows. Their experience in stress testing and image interpretation will enhance the skills and understanding of first year fellows and will supplement the faculty s role. FROM COCATS: Training in Nuclear Cardiology All trainees should know the general principles, indications, risks, and benefits of nuclear cardiovascular procedures, such as radionuclide ventriculography and myocardial perfusion and viability assessment. All trainees must receive basic training in radiation safety. Trainees need a minimum of 2 months of training; those who wish to practice nuclear cardiology must have additional training, as described in the Task Force 5 report. Differential Training Curriculum: Second or third year fellows will serve as role models for first year fellows. Their experience in stress testing and image interpretation will enhance the skills and understanding of first year fellows and will supplement the faculty s role. Dr. Martin will select interesting articles for the journal club, and second year fellows will be the discussants for the first 6 months of the year. Thereafter, first year fellows and nuclear medicine residents will be the discussants. High quality power point slide presentations are the format, coupled with an in depth critique of the article and its relevant literature. Requirements for Certification (for lab rotations):

10 There is a basic science curriculum which is essential for obtaining accreditation in nuclear cardiology. At Vanderbilt, this lecture series is given by faculty in the Department of Radiology and Radiological Sciences. The schedule and topics are listed in the handbook you will receive when you come to this rotation. If not completed here, then there are various commercial organizations for this training, but this will be at your personal expense. Level 1: This will be an exposure to the fundamentals of nuclear cardiology for a minimum of 2 months. Attending lectures, reading relevant literature, performing stress tests and interpreting radionuclide stress tests and attending conferences are the components of this training. The fellow should gain an acquaintance with practical methods of radiation safety regarding administration of radiopharmaceuticals and the dosimetry of these drugs and CT or radioactive sources for attenuation correction. The fellow should gain an acquaintance with PET imaging, including knowledge of the myocardial metabolism and tracer kinetics that allow measurement of metabolic processes. There should be a minimum of 100 total cases, including SPECT, PET and RVG. All the studies interpreted should be documented by the fellow to aid in any future certification process. Level 2: This level will provide exposure to nuclear cardiology for a minimum of 4 months. There should be a minimum of 700 hours of radiation safety practical experience, which is likely to occur in 4 months. This should lead to satisfying the requirements of the Nuclear Regulatory Commission for becoming an authorized user. There should be a minimum of 300 cases documented, including SPECT and PET and RVG, and the fellow should document hands-on experience in at least 25 patients who had perfusion imaging and 10 radionuclide ventriculographic cases, including radiopharmaceutical preparation, dose calibration, setup of gamma cameras and CT systems, setup of computers and image processing, plus reports. Radiation safety experience must include ordering and dose calibration, QC procedures, preparing doses, learning how to prevent medical events with unsealed radioactive products, procedures to contain spilled radioactive products, administering radioactive doses to patients, and eluting generators. All these criteria are spelled out in detail in the Taskforce 5 document referenced below. Didactic experience should occur over months, including lectures on radiation safety, radiation biology, and should be documented. There should be correlation with catheterization or CT angiography data in a minimum of 30 cases. Specialized training with PET should include a minimum of 40 cases. Level 3: This level of training is needed for a fellow who plans on a career in nuclear cardiology or directing a nuclear cardiology laboratory. The fellow should participate for a total of 12 months in a clinical nuclear cardiology program, have

11 experience in 600 or more cases, With this there should develop expertise in qualitative and quantitative interpretation of perfusion and ventricular function studies, including SPECT/CT and PET/CT and RVG. There should be active participation and responsibility in laboratory or clinical research. These details are spelled out in the Taskforce 5 document. For those fellows who wish a career involving PET imaging, a minimum one year period is recommended, with details spelled out in the Taskforce 5 document. Recommended Reading: Cerqueira MD, Berman DS, Di Carli MF, Schelbert HR, Wackers FJT, Williams KA: Task Force 5: Training in Nuclear Cardiology. J Am Coll Cardiol 2008; 51:368. Martin WH: Nuclear Cardiology Service. Publication supplied to each fellow during Nuclear Medicine rotation. Evaluation and Feedback: Fellows are evaluated at the end of the rotation with a competency based evaluation system Fellows are directly observed and given real time feedback on their performance Fellows participate in structured case discussions (ie, in cath conference) Level 1: see COCATS criteria Level 2: see COCATS criteria Level 3: see COCATS criteria Recommended Reading: see above.