Planning safe procedures

Making the correct treatment plan

This chapter focuses on steps you should take to minimize risk and prepare yourself and the patient for successful and safe procedures. You may be tempted to skip past to get to the action and give this section little more than a perfunctory glance. Do so at your own peril, every patient has the right to expect that they will receive timely and correct treatment and that an appropriately skilled practitioner will perform their procedure. The adage ‘ Proper Planning Prevents Poor Performance ’ applies in interventional radiology and heeding it will help you maximize your chances of achieving a successful outcome for the patient. Before rushing off, needle in hand, stop and ask yourself the following questions:

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Does the patient really need/want an intervention?
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Have you and the patient considered and understood the pros and cons of the alternative treatment options?
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Is the proposed procedure the most appropriate in the clinical situation?
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Does the patient understand what is in store and the potential risks and benefits?
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Do you and the patient have similar and realistic expectations for the outcome?
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Are you and the team prepared for all eventualities?

If you are unsure or have answered no, then seek advice and make sure that you document your discussions with colleagues and the patient. It is always better and safer to delay or cancel a procedure than to rush headlong into the wrong option.

Preparing for successful and safe procedures

There are three distinct aspects to consider when preparing for procedures, these relate to:

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The patient
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The team who will perform the procedure
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The environment before, during and after the procedure, including recovery and destination ward.

These must be addressed in advance of every procedure in the outpatient department, at multidisciplinary team meetings, on the ward, in discussion with clinicians and members of the radiology team. The amount of planning will vary with the complexity of the procedure and the needs of the individual patient but clear documentation is mandatory at each stage.

Patient preparation

The key elements required to ensure that patients are properly prepared for a procedure are evaluation and information. Each assumes that you understand the procedure yourself.

Evaluation

The focus of evaluation is the identification of factors which may increase the risk of the procedure. Complex procedures should be discussed at multidisciplinary team meetings where all the different therapeutic options can be considered.

Screening tests

Routine investigation (blood testing and electrocardiogram [ECG]) of all patients is unnecessary and merely increases the cost of patient care. In deciding whom to screen, consider the ‘invasiveness’ of the planned procedure and the likelihood of detecting an abnormality which would affect patient management. There is little evidence on which to base management, except in the case of prevention of contrast-induced nephropathy. The guidelines below are suggestions for screening and are not absolute; if in doubt, it is better to perform a non-invasive test.

Evaluation of renal function is indicated when the patient:

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Has a history of renal dysfunction
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Has a disease likely to impair renal function, e.g. hypertension, especially with peripheral vascular disease
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Is diabetic and has not had recent evaluation of renal function
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Has heart failure
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Is receiving nephrotoxic drugs.

Clotting studies are indicated when the patient:

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Has clinical evidence of a coagulopathy
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Has a disease likely to affect clotting, e.g. liver disease; therefore, it is unwise to perform a liver biopsy without knowing the coagulation status
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Is receiving medication that affects coagulation, e.g. heparin, warfarin or other anticoagulant or antiplatelet agents.

Platelet count is indicated in conditions that affect blood cell production or consumption, e.g. leukaemia, hypersplenism and cancer chemotherapy.

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Full blood count (FBC) is obtained in the context of bleeding but is less important than physiological status.

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Remember numbers may be misleading, e.g.:

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Haemoglobin can be normal for several hours after acute haemorrhage.
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Platelet number may be normal but function may be abnormal, particularly in patients on dual antiplatelet agents.

ECG is indicated when the patient:

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Has a history of cardiac disease
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Is to undergo a procedure likely to affect cardiac output or cause arrhythmia, e.g. cardiac catheterization.

Information

In order to decide whether to undergo treatment, patients need a basic understanding of their condition and how likely the proposed intervention is to alleviate symptoms or improve prognosis. They also need to understand the therapeutic alternatives and the relative risks and benefits of each approach to managing their condition. Expect patients to have researched their condition on the internet; your job is to help them to make sense of the bewildering mixture of fact and fiction they have found. For all but the most basic procedures it is best to see the patient in advance, either on the ward or in an outpatient clinic.

Be straightforward and honest about your ability and experience and do not be afraid to allow a patient the opportunity to seek a second opinion. Patients will respect this and it is the least you would expect from someone treating you.

Informed consent

Patients have a right to be given sufficient information to make informed decisions about the ‘investigation/treatment’ (these terms will be used synonymously) options available to them. Your role is to provide relevant information in a way that they can comprehend. The laws regarding informed consent vary from country to country; these guidelines are based on the current situation in the UK but the ethos is broadly applicable.

Recent case law in the UK has changed the focus of consent to consider what the ‘prudent patient’ would be likely to want to know. This means that patients should be warned of ‘material risks’ associated with a procedure, even if they are uncommon. For instance, acute limb ischaemia is a recognized complication of peripheral arterial angioplasty; this may require surgery to restore flow and could conceivably lead to amputation or even result in death. Although uncommon, these risks must be mentioned and the likelihood of these events occurring must be put into perspective. In the UK at least, this has significant ramifications for consent.

Material risk

In practical terms, a ‘material risk’ is anything that a ‘reasonable person’ in the patient’s position would be likely to consider important. This includes the common and serious side-effects (and their management) of the proposed procedure. It also encompasses anything that the doctor would presume to be important to the individual patient. For instance, ischaemia of a fingertip would be expected to have particular relevance to a concert pianist, as it would potentially result in a loss of livelihood.

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When considering ‘material risk’ ask yourself what you would want to know before agreeing to treatment. You should comment when the treatment is complex, unfamiliar or involves significant risk for the patient’s health, employment, or social or personal life. Document the key elements of any explanation and record any other wishes that the patient has in relation to the proposed treatment.

Consent issues

A qualified doctor who understands the risks and side-effects of the procedure should be responsible for obtaining consent for treatment. Usually the doctor performing the treatment is in the best position to provide this information. If this is not practicable, the doctor may delegate to an appropriately experienced colleague. You must provide a balanced explanation of the treatment and alternative management options along with the risks and benefits of each. Include things a prudent patient might want to know, such as:

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The general nature and purpose of the proposed treatment, including analgesia, sedation and aftercare
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Are there alternative therapeutic options? This might include doing nothing, optimizing medical therapy, surgery or other interventional approaches
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Information about those performing the procedure including:
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  The name of the doctor with overall responsibility for the patient
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  Names of the relevant members of the doctor’s team, e.g. anaesthetist and surgeon
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  The experience of the operator/team with the procedure.
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What are the ‘material risks’ of the procedure and how common are they?
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Realistic expectations of the outcomes of the procedure, e.g.
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  What is the likelihood of the procedure being a technical success?
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  Will this have the clinically desired effect?
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  Is the treatment a cure?
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  What is the likelihood of recurrence?
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Will this treatment strategy impact on their future management?

The form of the explanation and the amount of information provided vary depending on the patient’s wishes, their capacity to understand and the nature and complexity of the treatment. The patient should be allowed time to consider the information and must not be pressurized to make a decision. The patient must be told that they can change their mind or seek a second opinion at any time without prejudicing the care.

Review the patient’s decision close to the time of treatment. This is mandatory when:

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Significant time has elapsed since consent was obtained. Many consent forms have a section to allow reaffirmation of consent.
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There have been changes that may affect the treatment strategy or outcomes.
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Someone else has obtained consent.

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