Best Practice in Nuclear Medicine Part 1 a Technologist’S Guide Contributors Ignasi Carrió M.D

Eur e opea icin n Association of Nuclear Med

Best Practice in Nuclear Medicine Part 1 A Technologist’s Guide Contributors Ignasi Carrió M.D. Sylviane Prévot President of the EANM Chair, EANM Technologist Committee Professor of Nuclear Medicine Chief Technologist, Radiation Safety Officer Autonomous University of Barcelona Service de Médecine Nucléaire Director, Nuclear Medicine Department Centre Georges-François Leclerc Hospital Sant Pau Dijon, France Barcelona, Spain Helen Ryder Suzanne Dennan (*) Clinical Specialist Radiographer Deputy Radiographic Services Manager, Dept. of Diagnostic Imaging Dept. of Diagnostic Imaging St. James’s Hospital St. James’s Hospital Dublin, Ireland Dublin, Ireland Linda Tutty Wendy Gibbs Senior Radiographer Delivery Manager Dept. of Diagnostic Imaging Dept. of Nuclear Medicine St. James’s Hospital Guy’s and St. Thomas’ Hospitals Dublin, Ireland London, United Kingdom Anil Vara Julie Martin Clinical Modality Manager – Nuclear Medicine Director of Nuclear Medicine Service Dept. of Nuclear Medicine Dept. of Nuclear Medicine Royal Sussex County Hospital Guy’s and St. Thomas’ Hospitals Brighton, United Kingdom London, United Kingdom Editors Brendan McCoubrey Suzanne Dennan (*) Radiation Safety Officer Sue Huggett Dept. of Diagnostic Imaging Senior University Teacher St. James’s Hospital Dept. of Radiography Dublin, Ireland 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.

References Linda Tutty 3.6. Multidisciplinary Team Workin Suzanne Dennan 3.5. Lifelong Learning andCP Suzanne Dennan 3.4. Education and Trainin Wendy GibbsandJulieMartin Practice3.3. Best for Appraisa Wendy GibbsandJulieMartin Practice3.2. Best for Inductio Wendy GibbsandJulieMartin Practice3.1. Best for andSelectio Recruitment Linda Tutty 2.3. ClinicalResearch Policie Helen Ryder 2.2. Protocols andPolicies Department inNuclearMedicine Brendan McCoubrey 2.1. Available Guidelines 1.7. Accreditation Awards’‘Quality 1.6. Audit/Clinical Governance 1.5. BusinessandStrategic Planning Assessments andIncident 1.4. Risk Training/Practice –Budgeting 1.3. Cost Implications 1.2. Stock Control 1.1. Patient Workflow Scheduling Efficient and Anil Vara Service 1–ManagingaNuclearMedicine Section M.D Ignasi Carrió Introductio Sylviane Prévot Forewor Contents – Staff Aspects of Best of 3–Staff Practice Aspects Section 2–Guidelines/PoliciesSection /Protocols d .

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3 1 5 5 5 4 4 3 3 2 2 1 1 1 1 1 1 . 2 9 7 6 4 1 8 6 8 2 9 0 9 8 7 5 3 1 9 7 7 5 4 EANM Foreword Sylviane Prévot

One of the major achievements of the EANM Quality is not just a nice concept : quality is a Technologist Committee in the past 2 years state of mind. I hope this brochure will meet has been the publication of a series of bro- the expectations. Contributing to the qual- chures “Technologist’s guides” that was ini- ity assurance of Nuclear Medicine practice it tially planned with two main goals: to en- may also become a useful tool for motivated courage Nuclear Medicine Technologists’ technologists in the optimization of the overall (NMTs) reflection on the quality of their daily quality of healthcare in Europe. practice and to advance it if necessary. Sylviane Prévot The aim of this third volume is to provide Chair, EANM Technologist Committee an introduction to best practice in Nuclear Medicine considering three main items : management of a modern day Nuclear Medicine service, clinical guidelines & protocols, management of human resources. The impact of policy and legislation on best practice will be the purpose of a second part to be published at the EANM Congress 2007 in Copenhagen.

I am grateful for the efforts and hard work of all the contributors, who are the key to the content and educational value of this booklet. The most essential and relevant aspects of best practice are emphasized here. Many thanks to Suzanne Dennan for her dedication to the success of this guide. This publication wouldn’t have been possible without Bristol- Myers Squibb Medical Imaging support. Their collaboration and generous sponsorship was greatly appreciated.

Introduction Ignasi Carrió M.D.

Nuclear Medicine departments offer a large Nuclear Medicine therapy has also been grow- diversity of diagnostic and therapeutic pro- ing far beyond the established treatment of cedures, which often play a central role in pa- benign and malignant disease of the thyroid. I- tient management. At the same time, the field 131 when linked to metaiodobenzylguanidine is constantly evolving with new procedures is used in the treatment of neuroendocrine being continuously introduced. In such a rich malignancies, such as pheochromocytomas and developing scenario, adherence to best- and neuroblastomas. Newer ligands target- practice guidelines becomes crucial to offer ing the SS2 receptor subtypes are emerging, best patient care. labelled with Yttrium 90, Lutetium 177 and other radionuclides. Pain palliation in ad- Nuclear Medicine technology is a demanding vanced metastatic and skeletal prostate and and sophisticated profession. The continuous breast disease has become available, with one developments in technology, radiopharmaceu- third of patients showing excellent response ticals, procedures and patient care make it one to a variety of radionuclides, including stron- of the most rapidly evolving health care profes- tium 89-chloride, rhenium-186 as etidronate, sions. For example, novel targets for imaging samarium-153 as ethylene-diaminetetrameth- have emerged, such as labelled glucose for the ylene phosphonate. Several labelled antibod- imaging of cancer, labelled somatostatin tracers ies have been entered in clinical trials and for the imaging of neuroendocrine disease, beta some have now been approved as specific CIT homing onto the dopamine transporter for treatment options, such as Zevalin or Yttrium- the investigation of patients with movement dis- 90 labelled ibritumomab tiuxetan and Bexxar orders. Progress is coming in the imaging of the – I-131 labelled tositumomab. Alzheimer’s disease, the imaging of atheroscle- rotic plaque and the imaging of angiogenesis With such continuing developments and in- and hypoxia. Sentinel lymph node detection has novation, best-practice may become a mov- changed the surgical management of patients ing target. Clearly, best-practice guidelines presenting with early breast cancer. At the same must be developed and implemented at the time, all diagnostic procedures have benefited European level that help Nuclear Medicine from major progress in instrumentation; and in departments to provide best patient care. Up- the last 5 years, the emergence of multimodal- dated procedural and clinical guidelines are ity imaging has become routine. Conventional available from the EANM website for many of gamma cameras have been linked to advanced the well established diagnostic and therapeu- CT scanners (SPECT/CT) and modern PET scan- tic procedures. Adherence to such guidelines ners have been linked to multi-slice CT devices is highly desirable to harmonize patient care (PET/CT). across the diversity of European countries. Eu-

ropean Nuclear Medicine technologists prac- petence, must be part of best-practice codes tice Nuclear Medicine in departments where in any Nuclear Medicine department. most of these procedures are performed in a patient’s diagnosis or follow-up. As members Like all healthcare professions, Nuclear Medi- of their institutional health care team, they cine must move with the times, changing and also function as patient advocates, educators, adapting its principles and relationships, ac- health care researchers, technical and therapy knowledging the expectations of patients and specialists, and interdisciplinary consultants the developing practice of other healthcare and play a key role to offer best clinical prac- disciplines. Like all healthcare professions, only tice. Nuclear Medicine must embrace the prin- by understanding, accepting and adapting ciples of best-practice as the basis for clinical to these changes can Nuclear Medicine offer judgement, within the context of working as best-practice and retain its relevance within part of a multi-disciplinary team in medical medicine and society. diagnosis and therapy. Within such multi-disciplinary teams, Nuclear Medicine technologists Ignasi Carrió, M.D. must play a leading role in establishing clinical President, EANM standards and clinical protocols.

In order to offer best practice, continuing education is essential. The education process in Nuclear Medicine includes graduating from an accredited programme, completing a summary of clinical competence and completing a professional certification examination 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, lifelong learning is a core value for all health care professions. Therefore, entry-level education in Nuclear Medicine must be supported by both formal and self-directed professional development programmes. All these programmes, including cognitive, affective and clinical com-

Section 1 – Managing a Nuclear Medicine Service 1.1. Patient Workflow and Efficient Scheduling Anil Vara

Introduction Diagnostic Imaging An efficient Nuclear Medicine department Diagnostic imaging makes up the bulk of relies mainly on good scheduling of patients examinations in Nuclear Medicine. Efficient for an efficient workflow. Nuclear Medicine scheduling for this is mainly dependent on has various types of examinations, each with staff availability, gamma camera numbers, its own time scale, preparation, and various and gamma camera types. Some centres may complications. Diagnostic imaging is the most operate with a single gamma camera, whilst common type of examination most centres some departments may have multiple gamma schedule routinely. cameras at their disposal.

Table 1: Example outline of a day list illustrating flexibility in Nuclear Medicine exam type. Courtesy of Kingston NHS Hospital, Surrey; Vara 2001 TIME STUDY PATIENTS NAME COMMENTS 09:00 URGENT BONE 09:15/09:30 RBC/MECKELS/MAG3 09:45 10:00 BONE/DMSA INJ 1 10:15 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 BONE/DMSA SCAN 2 13:45 14:00 BONE/DMSA SCAN 3 14:15 14:30 BONE SCAN 4 14:45 15:00 BONE SCAN 5 16:30 BONE SCAN 6

One Gamma Camera Department Other types of examinations Centres that have only one gamma camera Scheduling non-imaging examinations are most likely to schedule various types of alongside diagnostic imaging is needed in examinations during a working day. Careful most Nuclear Medicine departments. These planning and organisation is critical to achieve could be exams such as GFR, red cell mass this, in light of the complexity involved in vari- or therapeutic administrations. In-vitro based ous Nuclear Medicine exams. Block booking exams are mainly performed by trained staff particular exams could be difficult to achieve, that are commonly multi-tasking and involved whilst having the flexibility for all types of ex- in other areas. Rotating staff through all areas ams over a working day would be more effi- maximises expertise and is best for flexibility cient. Table 1 illustrates an example of a typical in scheduling non-imaging work alongside day’s workflow on a single gamma camera. diagnostic imaging. Scheduling in-vitro work has to be carried out with care to ensure ad- The outline of the example takes account of equate capacity is maintained at all times in the various camera times required for each all areas of the department. exam, whilst fully utilising all the capacity available to schedule the various exams. This Therapy is very dependent on key profes- type of day diary can be easily set up for single sionals such as consultants and/or medical camera departments, but care must be given physicists. Usually in this case, scheduling of on examinations that are higher in demand. these patients is independent of other Nucle- Systematic review of all workflows should take ar Medicine work, but attention is needed if place regularly, especially following a protocol technological staff have delegated responsi- review. bility in Therapy.

Multiple Gamma camera departments Scheduling on multiple gamma cameras can be flexible, but the main advantage is that block booking of particular exams can be achieved more efficiently than in single camera departments. The option of block booking for higher demand studies, for example Myo- cardial Perfusion studies such as Octreotides or MIBG can be better streamlined, not hin- dering ‘common’ types of work such as Bone scanning etc.

Section 1 – Managing a Nuclear Medicine Service 1.2. Stock Control Anil Vara

Introduction minimise costs and waste. Commercial com- Stock control in Nuclear Medicine is an es- panies are now offering software packages to sential task for the efficient operation of the carry out the overall management of radiophar- Nuclear Medicine department. macy stock, with options built in to warn of low stock levels and automatic updating. The types of stocks routinely handled are: Ordering long-lived radiopharmaceuticals such 1. Radiopharmacy consumables as 111In Octreotide, I131MIBG etc. is usually carried 2. Clinical consumables out on a per usage basis. 3. Pharmacy consumables 4. Administrative consumables 2. Clinical Consumables Clinical consumables range from frequently 1. Radiopharmacy Consumables consumed items such as syringes, needles, Radiopharmacy consumables include cold gloves, sharps bins etc to items that are used kits, nuclides and items used for radiopharma- less frequently such as, ventilation kits for aero- cy production. Cold kits have to be carefully sols, specialised nursing aids etc. managed, as their requirement is very much dependent on the particular demands for The golden rule is not to overstock on these certain types of examinations, which can vary items, which is a common practice in some over quite short periods of time. Most centres Nuclear Medicine departments. This can lead have purpose built databases or spreadsheets to excess requirement for storage space, the for managing these stocks. These are usually risk of items expiring and of accumulating for the purpose of recording incoming stock unused items which would incur costs. Com- and auditing the level of use based on the monly, these types of stocks are controlled and service need. Such databases allow a concise ordered as a common pool with other modali- record allowing all aspects of stock control to ties such as Radiology and CT. By averaging out be monitored but there is still an element of consumption, this does achieve an adequate good communication needed between the stock of clinical consumables which can be production service and the diagnostic service reviewed weekly or every fortnight. Most hos- to reduce the occurrence of overstocking and pitals operate an online ordering system, direct to accommodate any service changes. When to their stores and even set up standing orders. ordering cold kits and 99m Tc generators, this is Standing orders would be practical for consum- best accomplished by a standing order with the ables that have average usage (per week for supplier, but a regular stock take every month example) and the average usage is sustained. is essential in conjunction with this, in order to

3. Pharmacy Consumables Nuclear Medicine routinely has to stock both drugs that are commonly used as part of the examinations and essential drugs which are used for intervention when faced with emergencies. Usually a standing order with the pharmacy department would be best to manage the incoming stock of drugs with the advantage of cross charging made easier to budget for every month. Additional drugs can be requested when stock is low. The most crucial element is that pharmacy drugs are all checked for expiry regularly and that drugs used should be replaced as soon as possible. In these cases, it is often useful 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 for the efficient clerical operation of Nuclear Medicine. Again overstocking could result in unnecessary costs to the department. The common practice for most institutes is that administration 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.

10 reviewed regularly especially when a vacancy get against each one. Pay budgets should be institute accountant will assign an annual bud staff and their funding have been agreed, the Once staff. for allocated is budget pay The 1. this best. achieve can accounts trading local up ting receive.will Set department the income the to account would This work. hospital) (other external and hospital) the (within for internal In the UK it is common practice to cross charge 3. 2. 1. down into thefollowing components: broken usually are budgets Departmental accounted for. is income all that so department, the within activity all on audit strict and keeping data called Payment by Results, and requires good is This completed. activity the by paid are NHS the in are that departments UK, the In to andflexibility. have efficiency order in properly budget departmental the manage to important is It pressures. service Health/Trust overall with associated usually ficient operation of a NuclearMedicine service, Financial pressure is always a concern for an ef Anil Vara –Budgeting 1.3. Cost Implications Service 1–Managing aNuclearMedicine Section

Pay department Non-Pay –Allothercosts Pay –Staffcosts noe Py ht s eevd y the by received is that Pay – Income - - -

11 correct account so that a review at the end the at review a that so account correct the to charged be should Items spending. over prevent to required is budget this of costs from previous years. Good management each account based on an estimate of the true to limit budget a place will accountant tute insti maintenance,the provisionsetc.Again, radiopharmacy, equipment, as such counts ac individual into down broken usually are These service. Medicine Nuclear the running in involved costs all represents budget This 2. within theexistingbudget. casionally higher demand areas can be funded essential, as service needs do change and oc to maximise numbers. Reviews of this kind are gradings staff restructure and/or posts tional addi for need the prove to opportunity an provide and time current the at needs vice ser the of review a allow would occurs.This kind, kind, for which a bulk payment is taken in one some of wouldcontract this a of be example An month. particular a until all at used not is account an against set budget a that found easier.be Occasionally,however,may view it yearreof end properly,the account making across accounts, it is possible to balance each adjustments slight making By overspent. ing not being used whilst others are at risk of be year it may be found that certain accounts are financial the during as important, is account each of review (monthly) Regular year. ing adjustments need to be made for the follow where of reflection true a shows year the of Non-pay ------EANM month only. In these cases, accounting methods can adjust for this so as not to give a false impression of the account.

3. Income Most departments will receive income, mainly for services to outside institutes usually via service level contracts or monthly activity re- charges. These budgets are reviewed at the end of every financial 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. If excess income is obtained, this can be used for off-setting any other budgets such as pay or non-pay, but this is rare once annual budgets are set.

12 When an incident does occur, it must alwaysoccur, must does it incident an When Medicine, even when assessments are made. Unfortunately incidents do happen in Nuclear trainingIncident risk assessment. defined withinthe be should supervised or controlled as nated tions 1999). Areas desig in Nuclear Medicine regula Radiation (Ionising regulations IRR99 In the UK, all risk assessments must conform to Table assessments 1:Risk During place. or miss” taken “nearcident has in an if or year a once preferably reviewed, regularly and Medicine Nuclear of area each for drafted be should risk radiation sociated in the assessed areas. The assessments for as read by all personnel who would be working each area of the department. They should be Advisor), so relevant staff are awarerisks in of on advice form the RPA Protection(Radiation These assessments are drafted, usually based health andsafety issues. and risks radiation on based are assessments commences. The most common of types risk Medicine Nuclear within work new any fore be out carried be should assessments Risk assessments Risk Anil Vara Assessments andIncident 1.4. Risk Training/Practice Service 1–Managing aNuclearMedicine Section Waiting area room Injection Camera roomGamma Area Dose ratesDose from patients, radioactive patientcontaminants rates staff,Dose to authorised sealedandunsealedsources, patients from staff to sources,doses sealed contaminants, sources,patient Unsealed Types ofrisksassociated - - - - - 13 ample isshown in Table 1: ex An Medicine. Nuclear within room each on based assessments of series a produce to best usually is It concise. be and possible as simple as kept be should assessments Risk 5. 4. 3. 2. 1. The 5 steps to a risk assessment are as follows: possible. as much as risk the minimise to updated be must measures control process, review the The trainingshouldconsistofthefollowing: work. commencing before undergo, should working in relevant areas of Nuclear Medicine staffall which programme, training a have should supervisor protection radiation The possible. if further, minimised be can associated risks must take place following the incident, so the review A filed. records with documented, be Review Review plan/recordsAction Evaluating therisks Control measures inplace Identifying thehazard - EANM 1. To read and follow the local rules for the department 2. To be familiar with the procedures when a radiation incident occurs 3. To be aware of the documents that need to be completed when a incident occurs 4. To be cognisant of the staff that have to be notified.

The local rules should be concise and as short as possible. They should contain key information such as contact details, types of sources within the department, decontamination procedures, and systems of work, operational procedures and contingency plans.

Generic hospital incident logbooks can be used for logging incidents. Although a purpose made record is just as good. Following an incident, a record should be drafted as soon as possible. Depending on the severity of the risk, incidents should be followed up quickly, reviewing systems of work to minimise the risk. All incidents should be discussed at the next radiation safety committee, where further support can be acquired, if needed.

and in conjunction with the trust accountant. accurately drafted be should case business proposal.business forconsideredthe be The to options illustrate and together placed be to evidence the all allow docu will which ment, essential the is case business The Business case 5. 4. 3. 2. 1. considered are: be should that evidence of types The sible. its possible implementation as smooth as pos make and forward plan the take to available is evidence the all that important is it nique, tech new a even or staff equipment, new as When an idea needs to be taken forward, such planning Initial the rapidchangesthatwilloccur. have toservices be adapted in order to meet and medicine, in area growing a is Medicine Nuclear made. be to need changes future or immediate when especially important, very is Medicine Nuclear in planning Business Anil Vara 1.5. BusinessandStrategic Planning Service 1–Managing aNuclearMedicine Section

declined EANM UK) Capacity and demand data for the Nuclear the trust/organisation Financial fundingandsupport Recommendations Recommendations and audits from recog- Medicine department Medicine (National Institute of Clinical Excellence, Clinical of Institute (National mat n h srie f h pa is plan the if service the on Impact NICE e.g. groups professional nised Any income revenue or other benefits to benefits other or revenue income Any - - -

15 of this section, a list of options should be listed. this. end affect mayFinally, the that at posed pro changes any and available equipment) and staff (current capacity and service) the tion of the demand (amount of work entering ed. This will be based on graphical representa pacity of the current service should be includ ca and demand on section a Followingthis, commissioning bodies etc is well suited here. such as from bodies,regulatory government, tion and purpose of the case. Good evidence introduc an with begin should section This 1. shouldbeincluded: essential sections followingthe case, business a drafting When Essentials ofthebusinesscase implementation. submitted to the trust board for approval and prepared,is case business a Once usually is it ments behind each of the above listed op listed above the of each behind ments require finance the listing by begin should It case. the proposed for finance the arguing Thisshould be section used for detailing and 2. business case. the rejected board trust the if service the on impact the including possibilities, all reflects case business the so Nothing’option, a ‘Do any business case. This should always include in considered be still should options all case, new the support to evidence have will you This is called an “options appraisal”. Although, Executive summary Economic case ------EANM tions. This is called an “economic appraisal”. All finance initiatives, including negative im- pacts, should be included under each option.

Following this, an assessment of the risks and benefits of 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 and negative aspects of each option. All associated risks and benefits should be included to make the case look strong. The outcomes of the scoring can be presented in a results section, followed by a simple conclusion.

3. Finance and recommendations This last section should indicate the amount, source and pressures of the financial support needed to justify the best option. Usually at this point, prior agreement of the source of funding will have been obtained and this will need to be documented here.

The final recommendation should highlight the best option to proceed with. The data provided in the relevant section should agree with the department’s recommendations, and if the evidence is clear, usually the business case is accepted. Occasionally, one or more options may be suitable; and in these types of situations it is very difficult to agree on the case. But, when possible, if there is just one feasible option in the recommendations, it works to the department’s advantage.

16 ideas from these meetings should be taken taken be should meetings these from ideas and Discussions case. further any support these are used to implement any changes and Generally once the group agrees to the results, for feasibility to improve patient management. any new evidence that arises can be discussed that best practice is always implemented and The aim of the sub specialty group is to ensure 3. 2. 1. lowing areas: Audits within the service should cover the fol methodology. and aim definite a with begin should they up, set are projects audit When leadonthis.normally would Medicine, Nuclear and Radiology as such areas, speciality within employed cally staff from each clinical area. A person specifi The audit group should comprise of essential this. perform to up set be should equivalent) (or teams governance Clinical medicine. of part other any with as Medicine Nuclear in essential are flourish) will excellence clinical which in environment an creating by care, of standards high safeguarding and services for continuously improving the quality of their through which organisations are accountable accuracy) and clinical governance (the system Audits (examinations of records to check their Anil Vara 1.6. Audit/Clinical Governance Service 1–Managing aNuclearMedicine Section

Evidence towards businesscase anew patient care practice practice Changes in service provisions with best with provisions service in Changes clinical of implementation or Change - -

17 to auditors. any external available and published, even documented, well be should areaudits made.decisions All forward to management meetings where final

EANM Section 1 – Managing a Nuclear Medicine Service 1.7. Accreditation ‘Quality Awards’ Anil Vara

Accreditation towards a good Nuclear Medi- cine societies will draft polices and procedures cine service is always an indicator of high which should be followed. achievement and movement in the right direction. Essentials of a good quality service Reviewing current practice should give an should include opportunity to enhance the service or deal with a concerning situation. Reviews should 1. Good written policies and procedures for be made in line with local or national audit the department programmes/data and should be included 2. Practice that complies well with the local across the whole function of the department regulations including staff competencies. 3. A review structure that covers all aspects of Nuclear Medicine Taking the department’s work forward to Na- 4. A department that liaises with other insti- tional or European meetings is an essential tutes within a local area and gets involved practice to demonstrate to other institutes with local activities to help maintain a good how the department is progressing and to level of service. share new initiatives. Usually single or joint departmental ventures are undertaken. Most Well written policies and procedures are es- departments do find it difficult to take this sential. They help maintain professional and forward, due to service and staff pressures, but safe practice in Nuclear Medicine as well as this should be encouraged as far as possible. help develop the service through audits and This is why joint ventures can make it easier. reviews.

Practice in conjunction with regulatory bodies is very important. For example, in the UK, the Department of Health has written various documents that require compliance. Although the practice associated with implementing these documents will vary from 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 of poor quality. Professional institutes such as National and European Nuclear Medi-

18 evant authorities at both European level and Europeanlevel both at authorities evant rel by provided guidelines existing the of section cross a given, links the following By requirements. toevant theirservice rel practices those covering guidelines local specific derive should institutions individual quality. From these Generic Quality Guidelines, overall affecting characteristics performance Generic Quality Guidelines, which outline the are procedures therapeutic and diagnostic individual of aspects performance covering Of greater relevance than detailed guidelines provided bytailored theinstitution. service of the available guidelines that impact on the institutional level to incorporate those aspects an at guidelines clinical of development the http://www.eanm.or pean Association of Nuclear Medicine ( Euro The boundaries. national and regional across apply readily not do guidelines that mean delivery service and practice clinical in differences and substances radioactive of administration the on Regulations European of interpretation National practice. and tion legisla European evolving of context the in formulated been have which guidelines the to focus it is on necessary world.particular In the throughout service Imaging dionuclide Ra a of provision the with concerned ties authori relevant various the by conducted been has which research, existing the on draw to important is it Medicine, Nuclear in practice best on document a preparing In Brendan McCoubrey 2.1. Available Guidelines 2–Guidelines /PoliciesSection /Protocols g recognises the need for EAN M ------) 19 on eachsociety’s website. Nationally produced guidelines can be found php?navId=5 http://www.eanm.org/pat_info/links. address: following the at found be may Societies and Further links to the International Associations International Links guidelines/guidelines_intro.php?navId=5 http://www.eanm.org/scientific_info/ EANM website atthefollowing address : areGuidelines availablefor the downloadon association. of theparticular history the concerning given is introduction national and international institutions. A brief resultant from the research assimilated by the worldwide can be found. These guidelines are 7 4 EANM Section 2 – Guidelines / Policies / Protocols 2.2. Protocols and Policies in Nuclear Medicine Departments Helen Ryder

A cornerstone of good practice in a Nuclear protocol is to list the technical factors required Medicine department is the development to complete the scan. These factors can in- and usage of protocols and policies for that clude: particular unit. Of differing origins, protocols tend to be an amalgam of standard scanning • Equipment used – in a multi-camera de- techniques with local radiological preferences partment some equipment may be more whereas policies are normally devolved from suitable than others. Myocardial perfu- legislation regarding the use of diagnostic sion imaging generally requires the use of radiation or the health and welfare of the a multi-tangential dual-headed gamma patient. camera; brain imaging may best be facili- tated by utilising a dedicated triple-headed So – who uses these protocols? system. The development of protocols is intended to standardize technical factors, timing of imag- • Quality Assurance and pre-set Gamma ing and the views obtained during imaging Maps – when using rotating cameras, or to provide the best information from which differing or multiple isotopes, preliminary the scan may be reported. By making these QA and gamma maps may need to be per- protocols available within the department, formed or defined. either electronically or on paper, new or rotating staff/personnel may be kept up to date • Radioisotope – isotope channel, peak and on latest changes in techniques. It also acts acceptance window to be used. as a reference for examinations that are not regularly performed by the department. • Acquisition Parameters :

Reference to written protocols can also alert Matrix size – can vary either for type of acquisi- staff members to the individual needs of the tion required (dynamic; planar; tomographic) reporting clinician. Most departments have or within a specific acquisition (e.g. The vas- more than one member of the medical staff cular/dynamic and blood pool/static planar who undertake and oversee scanning ses- phases of bone imaging). These are usually set sions, and adaptations by scanning staff to within the acquisition protocol logged onto their preferred techniques are of vital impor- the scanning computer. tance. Type of acquisition – e.g. dynamic, static, whole- Developing protocols body, SPECT, gated. A starting point in preparing an examination

20 • performing physical exercise. amination may be appropriate e.g. difficulty in Physicallimitations may also define which ex dipyridamole.oradenosine eithergiven be asthmaticthatnotedpatientsnotshould be forcalmyocardial stress procedures, shouldit pharmaceutichoosingForexampleawhen tal protocols, for medical and physical reasons. examinations or, more relevant in departmen Contraindications can apply both for choice of tection/publication/doc/118_en.pd http://ec.europa.eu/energy/nuclear/radiopro is available at the following web address: tion 118 “Referral guidelines for imaging”, which in their guidance document Radiation Protec has adapted the RCR referral guidelines for use rcr.ac.uk/index.as available through their website at ClinicalRadiology’Departmentof is a andof dures. The booklet is called ‘Making the best use for a wide range of diagnostic imaging proce whichoffersbooklet guidancethese cases in producedLondona hasinRadiologists (UK) propriateexamination.College ofRoyal The ap mosttherequestedscan be thenot may Indications/Contraindications the number of cycles completed. countorlimit,termsgated inofor studies by agesmay beended byreaching either timea Timeacquisition/countof statistics

the production of diagnosticproductionresults,theofscan Patient Preparation p . The European Commission – of vital importance in – in some casessome in – – some im some – http://www. f . ------21 • • •

imaging e.g. wholebody procedures, others tions can be performed as pre-programmed Images/views taken the protocol listings. days.These timingsincludedshouldbein minutes,or hourstheyintervals, betime certain performedat bescans thatquire Scantimedelays ment is scheduled. sentoutthetopatient whentheappoint in the protocols and any information sheets medication lists etc should be logged both The timings of such preparations as well as and/ortakenpre-betopostexamination. medication examination; to prior halted hydration requirements; medications to be rations should include the need for fasting; tions performed in the department. Prepa examina all defined for beshould these in the protocol list as above, it should be should it above, as list protocol the in framework of a successful scan is laid down protocols of Adaptation tive imagery. should be recorded for successful compara Lateral;Lateral.LeftPositional angulations Oblique;riorAnteriorRight Oblique; Right mayinclude: Anterior; Posterior; Left Ante ing Tc multi-planar imaging of lung perfusion us the instance, for includes, Thisrequired. demonstratephysiologytheto taken be toimagesplanarstatic ofseries requirea Section 2 – Guidelines /Policies 2–Guidelines /ProtocolsSection 99m -MAA.Atypical series of the lungs – someexaminations– re – whilst many examina – although the although – ------EANM noted that this protocol can be adapted their usage with reference to positioning for the medical condition of the individual of regions of interest. To minimize the sub- patient or for the requirement of a partic- jective effects of individual on the various ular requesting physician. An example of programs, protocols should be included this adaptation could be the basic Isotope to give step-by-step guidance in their ac- Bone Scan. Different patient history could curate application. influence the views taken during the examination in the following ways: • Relevant papers – copies of relevant arti- cles, papers, monographs and manufactur- - metastatic disease --- wholebody scan ers details are often useful to include within plus detailed static planar imaging of a protocol file, for additional reference and areas of interest. constant updating of good practice.

- osteo- or rheumatoid arthritis --- whole- A sample protocol is shown in Appendix 1. body scan plus static planar imaging of hands and feet

- infection/fracture e.g. diabetic foot -- - dynamic imaging of area of interest with three-hour delayed static planar imaging of relevant areas

- mandibular asymmetry --- static planar imaging of head plus SPECT imaging of mandible.

• Analysis protocols – many nuclear medicine examinations require that data be analyzed and presented in certain for- mats, especially where final figures are produced e.g. ejection fraction as a result of 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

22 Appendix 1:Sampleprotocol ofSt.James‘s (Courtesy Hospital, Dublin)

Scan Name: Scan Delay: Scan Display: Isotope channel: Camera: Parameters:Scan Radiopharmaceutical: Gallium

Indications for Indications Scanning:

Routine Routine Views: Collimators: Patient Preparation:

67 Whole Scans Body Day 2–no scans. Patient shouldfastfrom midnight,begiven Day patientto 3(48 hours) –Scan, fastandbegiven further As wholebody display, attach relevant static images. Label with Ga onDayScan 3(48hours)andDay 4(72hours) Day 4(72 hours) –Scan scan type and time (post injection) for andtime (postinjection) eachday.scan type Ga Axis Dual-head Gallium- 110MBq Due to lowandretained injected activity, tomography isnot Non-specific infection, inflammation,PUO;tumors; routine. bowel prep Wholebody scan (anterior and posterior) +planarsofareas andposterior) Wholebody scan(anterior of MEGAP sarcoidosis Day 1–Ga shouldgiveRadiologist injection. scan (72hrs),Ga interest if necessary at48Hoursand72hourspost-injection. interest ifnecessary bowel preparation for day. next 67 67 wholebodyscan(48hrs),Ga , 184,296,and388keV, 10-20%window widths 67

injection given injection –noscans. 23 67 67 planars(under ‘Other’ onprotocols list) Citrate (one patient dose). Section 2 – Guidelines /Policies 2–Guidelines /ProtocolsSection

67 wholebody

EANM Application of Departmental Policies tifying such patients lies with the referring Policies are designed to be applied within clinician, but all personnel involved are the Nuclear Medicine department as a whole, expected to actively ensure that radiation rather than on an individual scan basis. The is not used inappropriately with regard to policies generally are developed from the possible foetal irradiation. point of view of good practice, including radiation protection, health and safety, and All nuclear medicine procedures require infection control. All policies should be ap- that precautions be taken when admin- plied with the full knowledge and co-opera- istering radioactive materials to females tion of all branches of personnel within the of child-bearing age. Details can be set department (nuclear medicine physician/ra- locally but with regard to nuclear medi- diologist, physicists and radiographers/tech- cine procedures the ‘10-day Rule’ is most nologists) and should be made known to all often applied. This requires that all ex- clinicians and departments making use of aminations that include exposure of the the range of services offered by the Nuclear pelvic regions be deferred until the female Medicine department. is within the first 10 days of the menstrual cycle. Generally the only nuclear medicine Radiation Protection – procedure that can be carried out during • Radiation dose to the patients – as most pregnancy is an isotope lung perfusion nuclear medicine procedures require an study, and in many cases CT Pulmonary injection of radioactive material attached Angiograms are performed instead. The to a tracer, utmost care must be taken to European Commission provides practical ensure that the correct procedure has advice on the protection of pregnant pa- been selected to maximize diagnostic tients and breastfeeding mothers in the suitability; that the radioactivity of the guidance document Radiation Protection injected dose follows the principles of 100 “Guidance for the protection of un- ALARA (as low as reasonably achievable) born children and infants irradiated due or ALARP (as low as reasonably practi- parental medical exposures”, which avail- cable); that the patient has been given able at the following web address: adequate information prior to the procedure and such aftercare details as are http://ec.europa.eu/energy/nuclear/ appropriate. radioprotection/publication/doc/100_ en.pdf • Protection with regard to a possible pregnancy – the prime responsibility for iden-

24 •

Appendix 2. 2. Appendix in shown are sheets advice Sample apply. restrictions any and the for time which administered dose and the radiopharmaceutical undertaken, of the procedure type the ward regarding to is the patient with sent sheet an advice has completed, been procedure medicine a nuclear when or material radioactive of the injection – following examination cine medi a nuclear undergoing For inpatients concerned. staff pathology and the theater with and put in operation advance in confirmed been have should procedures such for protocols imaging, node sentinel following surgery during breast e.g. possible not is this Where examination. medicine nuclear the to prior performed be preferably should examinations these units, procedural diagnostic other in or department x-ray on day, the same in the either aminations ex of series a undergo to due is patient staff of protection Radiation – where a where –

- - 25 Section 2 – Guidelines /Policies 2–Guidelines /ProtocolsSection

EANM Appendix 2: Sample advice sheets (Courtesy of St. James‘s Hospital, Dublin)

DEPARTMENT OF NUCLEAR MEDICINE ST.JAMES’S HOSPITAL

Name of Patient:______

Consultant: ______Ward: ______

Date: ______Time: ______

The above named patient has attended the Nuclear Medicine Department for the following:

Scan Type: ______Isotope: ______

Activity: ______

The following precautions should be followed for a period of 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 carefully. 3. Soiled linen should be bagged and then stored for 24 hours before being sent to the laundry. 4. Pregnant staff 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 for the period of these restrictions. 6. Consider postponement of non-urgent investigations and treatments requiring staff working in direct contact with the patient for more than 5 minutes. 7. Patient should drink plenty of fluids and empty bladder frequently.

SPECIAL PRECAUTIONS: For further information, please contact the Nuclear Medicine Department.

26 cine Department backwiththepatient from theNuclear Medi indicated on the information sheet that is sent whichprecautions should be followed will be period.longerforfollowedtime aThe befor to have precautionsTc-99m, thanhalf-lives isotopestheselongerhaveof Because some Thalium-201, Iodine-123, Iodine-131) are used. ally, other isotopes (e.g. Indium-111, Gallium-67, isotopeOccasionscan.theafterhours 24 of generally only have to be followed for a period hours.6 effect,In this means that precautions half-lifeapprox.short-livedofaisotope with Technetium-99mrelatively(Tc-99m).a is This isfrequently most used is thatisotope The are advised and these are outlined below. nimise staff exposure, some simple precautions exposurewillrelativelybe low, orderin tomi whomtheycomeinto contact. Although this sourceaexposure asofactcan thosetowith effectivelyinjectedishe/she radioactive and cian wishes to assess. After the patient has been in the organ of the patient’s body that the clini selected so that it is processed or metabolised radioactivematerial.a pharmaceutical The is always by injection) that has been labelled with receive a pharmaceutical (usually although not Patientsattending for nuclear medicine scans Background for Patients NuclearMedicine Guidance Notes for NursingStaff Caring - - - - 27 5. 4. 3. 2. 1. Department: the NuclearMedicine from back patient the accompanying sheet instruction the on indicated period the for followedbe should guidelines followingThe Guidance tact the Nuclear Medicine Department. theNuclear Medicine tact For further advice or information, please con 7. 6.

Examination gloves and plastic aprons should Soiled linen should be bagged and then and bagged be should linen Soiled Pregnant visitors or small children should children small or Pregnantvisitors wherecontact possible. spent close to the patient and avoid close the laundry. to sent being before hours 24 for stored be cleaned up quickly and carefully. bedpans and dirty linen. Any spillages should be worn when handling urine bags, bottles, (lessthan0.5m)withthepatient. contact empty bladder frequently.empty for more than5minutes. in working direct contact with the patient vestigations and treatments requiring staff oftheserestrictions. period the for patient the visit to allowed be not Consider postponement of non-urgent in Pregnant staff should minimise the time the minimise should staff Pregnant In general, try to avoid unnecessary close unnecessary avoid to try general, In Patient should drink plenty of fluids and fluids of plenty drink should Patient Section 2 – Guidelines /Policies 2–Guidelines /ProtocolsSection - - EANM Health and Safety - The Nuclear Medicine department is also an The health and safety of both staff and pa- area of high risk when it comes to blood-borne tients must always be placed first in any con- viruses, most especially HIV, because of blood- sideration of policies. Regrettably incidents labelling techniques utilized for certain exami- can occur within a department ranging from nations. Sadly, instances where HIV infected a change or deterioration of the patient’s blood products were inadvertently injected condition that requires advisement of nurs- into the wrong patient have been recorded, ing or medial support to accidental injury to resulting in infection of the previously-HIV reactions to injected radiopharmaceuticals. negative patient. A report can found at: Although the latter are relatively rare, they http://www.cdc.gov/mmwr/preview/ are not unknown, and a policy and protocol mmwrhtml/00017383.htm should be in place to ensure a record is made of such incidents, and to register them with A proactive policy regarding the safe labelling the appropriate departments within the hos- and introduction of labelled blood products pital or with manufacturers. Most hospitals should be at the forefront of departmental have Risk Assessment teams that will log all in- infection control procedures. cidences and place them on permanent file. Similarly, a policy and protocol should be in Infection Control - place to assist and record incidents involving Protocols regarding the operation of infec- contamination of staff through needlestick tion control procedures should be included injuries. This should be co-ordinated with the in departmental protocols. With the rise of hospital’s Occupational Health Department. hospital-based infections such as MRSA and C.Dif., there is an increased need to be vigilant in the prevention of cross-infection. Rigorous cleansing regimes should be enforced when known carriers of infections are scanned in the Nuclear Medicine department, and protec- tive clothing and equipment utilized. Similarly, other pro-active steps e.g. usage of plastic pro- tective sheeting on gamma cameras and scanning tables should be used when an infectious state cannot be ruled out.

28 clinical testing. testing. clinical from obtained data of quality/integrity the and subjects trial of protection the ensure to included been have components of ber num A Guidelines: ICH the published (ICH) Harmonisation on Conference International the countries, throughout inconsistencies GCP international overcome to effort an In research. clinical in involved everyone to essential is GCP the of understanding and Compliance (GMP). Practice Manufacturing Good the to according produced be to need trials these in used radiopharmaceuticals ies, stud clinical medicine nuclear successful to backbone the form should GCP While radiation. ionising using research clinical to reference comprehensive most the resents rep Directive 97/43/EURATOM the view, of point legislation the From research. clinical in issue this with deal that publications have (WHO) Organisation Health Protection World the and Radiological of International Commission The principle. achievable) reasonably as low (as ALARA the to ence adher require radiation ionising involving trials Research Helsinki. of Declaration the in detailed as regulations and guidelines tional interna with accordance in environment practice clinical good a of framework the within out carried be should trials Clinical trials. research clinical in involved ev eryone for essential is (GCP) Practice Clinical Good the with compliance and Knowledge Linda Tutty 2.3. ClinicalResearch Policies 2–Guidelines /PoliciesSection /Protocols ------29 being of all trial subjects. The IRB/IEC should IRB/IEC The subjects. trial all of being The IRB/IEC protects the rights, safety and well- • • • • • • are: These regulatory requirementsregulatory for trials. relevant ethical concerns and meet applicable and other documentation adequately address protocol proposed the that establish should and/or well-being of the subjects. The IRB/IEC safety rights, the to add would information that where subjects the to given be mation infor additional for request may IRB/IEC The priate to the degree of risk to human subjects. views of each ongoing trial at intervals appro re out carry should It trial. proposed the for examine the qualifications of the investigator

Institution review board (IRB)/indepen board review Institution investigator andsponsor. ments; each subject; approve; and review (IEC) committee ethics dent Clinical trial responsibilities of the IRB/IEC, the of responsibilities trial Clinical Safety requirements; monitoring protocol; trial The aa adig n aciig require archiving and handling Data from consent informed obtained Freely - - - - - EANM Accurate dosimetry important for accurate calculation of patient Clinical trials involving the use of ionising ra- radiation doses, and in the case of diagnostic diation, as in the case of nuclear medicine, cases, to ensure that the radiation dose is as require special consideration with regard to low as possible. For therapeutic purposes, such the GCP. In addition to direct detrimental ef- as radionuclide therapy, there is a requirement fects, protection of humans against ionising for individual treatment planning by monitor- radiation requires consideration of the prob- ing the absorbed dose of the target volume ability of induction of stochastic effects, such and by considering possible detriment of non- as cancer and induction of leukaemia, even at target tissues. The effective dose may be used low doses. The benefit to society, by increase as an overall indicator of the risk on late sto- in knowledge, must outweigh the potential chastic effects to an average individual. Mean harm to the exposed individual. Such research organ doses and effective doses are typically trials should only be performed on a voluntary derived based on the data available in ICRP basis as set out in the Declaration of Helsinki. publications 53, 62 and 80. If no established biokinetic models exist for the applied radio- Different organisations have published specif- labelled tracer, dosimetry may be based on ic recommendations with respect to research animal experiments which should be then using ionising radiation in medicine. The WHO tested in pilot research on human subjects published a report in 1977 concerning the before any extensive research is planned. For use of ionising radiation and radionuclides radionuclide therapy investigations, where de- on human subjects for areas including medi- terministic effects may occur, doses to critical cal research. More recently the International organs outside the target volume should be Commission on Radiological Protection (ICRP) examined accurately and individually for each published a number of documents on the pro- patient. tection of patients with recommendations in nuclear medicine, including exposure in bio- Good Manufacturing Guidelines medical research (Bacher & Thierens, 2005). With the introduction of the European Direc- tive, all pharmaceuticals used in clinical studies From the legislation perspective, in the EU, must be prepared under good manufacturing the 97/43/EURATOM Directive represents the practice (GMP) conditions (De Vos et al, 2005). reference to clinical research using ionising Radiopharmaceuticals for clinical research pur- radiation (Bourguignon MH, 2000). In this poses must be manufactured in accordance document the justification and optimisation with the basic principles of GMP. Due to their of exposure following the ALARA principle short half-lives, many radiopharmaceuticals is crucial. With respect to optimisation, it is are administered to patients shortly after their

30 research studyinnuclearmedicine. understood before contemplating any clinical well be should it to linked policies the and GMP.GCP and dosimetry GCP,radiation ing surround legislation and guidelines the to given be should attention special medicine, nuclear in trials research conducting When process. production the of validation and monitoring the incorporate should assurance Quality crucial. is programme assurance quality the with compliance the Thereforecompleted. been has testing control quality all before Radiopharmaceuticals are nearly always used requirements ofGMPproduction. basic two the personnel, and environment area production the to given be should tion atten Special essential. is GMP toadherence controlmayretrospective. be Therefore strict quality the of elements some so production, - - 31 Section 2 – Guidelines /Policies 2–Guidelines /ProtocolsSection

EANM Section 3 – Staff Aspects of Best Practice 3.1. Best Practice for Recruitment and Selection Wendy Gibbs and Julie Martin

This Recruitment Chapter has been designed job part-time or a job-share. We should al- to enable you to help carry out the recruit- ways analyse the requirements at that mo- ment and selection process effectively. ment in time as well as consider future plans and requirements. The following objectives should be achieved: In order to define the requirements the fol- • The right candidate should be recruited, lowing steps must be undertaken: ensuring equality of opportunity for all candidates and that there is the right can- • Job Analysis didate for the right job in the right place. • Job Description • The recruitment process should take place in a timely and cost effective way. • Personal Specification

• Relevant legislation should be taken into Job Analysis consideration. It is necessary to ask what the job consists of and whether it is likely to be any different The three stages in the recruitment process than that of the previous postholder. Nuclear are: Medicine covers many areas and the skills required of a Nuclear Medicine Technologist • Defining Requirements post will vary. It may be that a specialist such as a Nuclear Cardiology Technologist is essen- • Attracting Candidates tial or a technologist who is newly qualified, to ensure that the right ‘mix’ of staff is there • Selecting Candidates supporting the clinical work and providing career progression. Defining the requirements when the vacancy occurs, the first questions to ask will be: Job Description (See Appendix 1) The following should be included: • Is there a vacancy? • The context of the post including respon- • If there is, who do we need to fill the post? sibilities and accountabilities

Sometimes it may be a case of reorganising • A small paragraph on the job summary the work or using agency staff or making the

32 • should beincludedintheadvert: which items of checklist a is following The forces and candidates available locally. simultaneously. This will depend on the market tising internally only or internally and externally likely to look. In some cases this may mean adverwhoarequalified taketo the on role are most theadvertisement placedis where candidates of recruitment should be selected. It is essential The most cost effective and appropriate method Advertising mance standards. career progression and in some cases perfor potential conditions, working as such point, this at provided be may information Other • • following information: The personal specification should provide the Personal SpecificationAppendix 2) (See •

zation thejob undertake opment dutiesifappropriate devel & research and responsibilities ing teach & professional clinical, managerial, encompass to responsibilities and duties Name & Brief details of employing organi Essential anddesirablequalifications Knowledge and experience required to required experience and Knowledge main the include will content job The - - - - - 33 view. view. inter for invited be then will candidates Successful consensus. a find and lists their reveal then will panel The provided. criteria to according scored be will They criteria. the meet that applicants of list a produce individually members panel specification, personal the in criteria essential the Using Shortlisting date may beset. At thispointtheinterview • • • • • • • remember to Points Interviews: course. of matter a as testing psychometric use may ganizations or Some appropriate. be may a presentation role, senior a in that suggested is it ever how test, a involve generally not will gists Technolo Medicine Nuclear for Interviews

Legible notes to be written by each panel panel each by written be to notes Legible apart from specifics related to the CV and and CV the to related specifics from apart interview. the during member The same questions should be asked asked be should questions same The Instructions onhow to apply Instructions Salary pointsofthepersonalspecification Key Training to beprovided roleJob andduties - - - - EANM particular issues that may arise out of the • Attention should be paid to the environ- application form and/or the interview. ment e.g. mobile phones switched off.

• Attention to any legislation such as the • Ensure preparation is timely. (UK) Disability Discrimination Act should be practiced. • Don’t leave candidate waiting and explain any unforeseen delays. • Preparation is essential both by individuals and the panel. It is necessary to decide • Ensure professional conduct at times who is chairing the interviews. In most throughout the process. cases this will be the most senior person. For a Technologist’s post it would be Upon completion of the interview, individual appropriate to have the Senior or Chief members of the panel give their feedback Technologist, Physicist or Radiopharma- and agree on the appointment (or not) by cist and/or a Medical Physician depending consensus. on the seniority of the post. Subject to the organisation’s policy, offers may • The interview should start with introduc- be made subject to; references, occupational tions and outline the interview process. health clearance and/or Criminal Record General biographical information would check. be examined first followed by examination of the application form and compe- A job offer will be sent out formally and com- tencies identified for the job. The panel mencement procedure and start date dis- will be listening and answering questions cussed. and the chairperson closes the interview by summarising and confirming future APPENDIX 1 actions. He/she may be responsible for Sample Job Description checking qualifications and details related Senior Nuclear Medicine Post Title: to occupational health and accommoda- Technologist tion. Service: Nuclear Medicine Hours of Work 37.5 hours • All panel members should be given a Reports to: Chief Technologist copy of the interview plan before the interview. Hospital / Organization Information (small paragraph: 2-3 lines)

34 3. 5. 4. 2. 1. responsibilities duties/key Main example and constructive supervision. andtechnical standards inallstaff by personal is essential. Encouraging the highest professional An understanding of the departmental protocols the range of all Nuclear Medicine investigations. To provide high quality diagnostic images across summary Job within theradiologyunit. works and radiopharmacy own its has ment cine and osteoporosis screening. The depart department undertakes general nuclear medi …. of The budget annual an has and staff … employs Department Medicine Nuclear The 3-4lines) (small description Services Nuclear Medicine

Perform all diagnostic & therapeutic proce Assist in cardiac exercise and pharmaco and exercise cardiac in Assist accordance with departmental protocol.accordance withdepartmental logical stress testing. ofnuclearmedicine. the practice in used drugs and radiopharmaceuticals administration Undertake of all diagnostic of self, patientsandstaff. Safety & Health forregard due with dures timely andaccurate manner. cedures using specialized equipment, in a Perform all clinical nuclear medicine pro medicine nuclear clinical all Perform Schedule all nuclear medicine studies in studies medicine nuclear all Schedule - - - - - 35 8. 12. 11. 10. 9. 7. 6.

Understand and apply all relevant legisla all relevant and apply Understand rvd ciia ifrain o h pa the to information clinical Provide consent, patient for responsibility Take cine investigations. investigations. cine medi nuclear all performing when tion cies. poli departmental and legislation ment govern with accordance in is practice working ensure waste, hazardous other and samples blood material, radioactive unsealed and sealed to exposure During patient. that to applicable as procedure the adapting and negotiating interpreting, whilst tient tails. de clinical relevant and identification for training and development. and training for resources appropriate of allocation and guidance advice, for manager line the with liaising while development sional profes continuing for Take responsibility ment. depart the in out carried being studies development and research in Participate personnel. to appropriate discrepancies for reporting responsibility take and equipment evant netk qaiy suac o al rel all of assurance quality Undertake Section 3 – Staff Aspects of Best of Practice 3–Staff Aspects Section ------EANM Standard Requirements Knowledge & Experience The post holder may be required to carry out Scientific, Technical & Clinical other duties in line with the grading of the • Minimum 5 year full-time experience post post.The job description may be subject to qualification. change and if so this will take place in con- sultation with the post holder. • Competent in all nuclear medicine procedures. The following policies should be adhered to at all times as per induction: Confidentiality, • Demonstrate an ability to work within a Code of Conduct, Equal Opportunities, Health multi-disciplinary team. and Safety, Smoking Policy, Data Protection Act, Terms and Conditions of Employment. • Competent in all data acquisition and analysis for nuclear medicine procedures. APPENDIX 2 Sample Person Specification • Able to recognise normal and abnormal bio distribution of radiopharmaceuticals. Person Specification Senior Nuclear Medicine Technologist • Provide a high quality professional standard of care to both patients and staff. Qualifications Essential: BSC Radiography or other relevant Legislation: Understand and comply with science degree with a post gradu- relevant legislation, national standards, and ate qualification in nuclear medi- professional guidelines. cine or Nuclear Medicine Degree (BSc Applied Science in Nuclear Skills: Medicine Imaging) IT: Proven IT skills to intermediate level on MS Office & Outlook. Desirable: Paediatric IV cannulation course ILS or ALS certificate Communication: Developed skills required Basic and advanced ECG inter- to work with patients and pretation staff from diverse -back EANM PET course or equivalent grounds. Capable of ex- CT accreditation tracting/imparting sensi- tive information.

36 (Restart process ifappointment (Restart Shortlist & agree onquestions/ Shortlist Agree method advertisement Review/ write job description jobdescription write Review/ agree detailsi.e. date, venue Induction of new employee ofnew Induction Recruitment FlowRecruitment Chart Close vacancy ifappointed Close vacancy Analysis &identificationof & write advert accordingly advert & write Select interview panel& interview Select candidate (or not)offer & personspecification Interview takes place takes Interview Appoint appropriate letter/issue contract format ofinterview APPENDIX 3 vacant post not filled)

37 contracts. issuing references, securing letters, offer and regret candidates, to invitation and tification no packs, short-listing of preparation packs, placement of advert, sending out recruitment organisation: an within Department sonnel HR/Perthe to fall followingtasks the Usually Section 3 – Staff Aspects of Best of Practice 3–Staff Aspects Section - - EANM Section 3 – Staff Aspects of Best Practice 3.2. Best Practice for Induction Wendy Gibbs and Julie Martin

Providing an effective and thorough induction not lose momentum and that s/he has ‘pro- ensures new starters are settled quickly into tected time’ to undertake and complete the their new working environment. It is about induction period. presenting the basics that experienced employees take for granted. Induction is a two-way process. The manager is responsible for ensuring: A good integration into the working environment must include the following elements: • That the information, explanation, guidance and direction needed is provided • General training relating to the organiza- within the induction plan. tion, including values and philosophy as well as structure and history, organizational • That mandatory training required has been charts etc. (see appendix 1) booked e.g. Basic life support, fire training etc. • Mandatory training relating to health and safety and other essential or legal areas. • That the new employee has the opportunity to ask questions and seek guidance. • Job training relating to the role the new starter will be performing. • That the new employee is effectively in- ducted into their job and competent to • Training evaluation, entailing confirma- undertake the necessary tasks safely. tion of understanding, and feedback about the quality of and response to the training. • That a checklist for induction is provided to ensure all areas are completed (see ap- It is the responsibility of a new employee’s pendix 2) and sign off as completed (see manager to ensure that induction training is appendix 3). properly planned. An induction plan should be issued to the new employee on their first The new recruit is responsible for: working day if not before and sent to all staff involved with the training. Although an induc- • Reading and absorbing all information pro- tion period should be specified, there is no vided throughout the induction period. right ‘induction time’ for new employees. In some instances an induction can span over a • Attending any training provided and re- few months. In these cases it is important for quired as part of the job. the new employee that the induction does

38 • •

the planned induction. the plannedinduction. isneeded.where helporclarity Completing and making the most out of out most the making and Completing Asking questions and seeking guidance seeking and questions Asking Organisational Chart APPENDIX 1 39 ing) to help facilitate the induction process. guidea (and are bynomeans allencompass The following checklists have been provided as Section 3 – Staff Aspects of Best of Practice 3–Staff Aspects Section - EANM APPENDIX 2 Induction Checklist

Employee Name: ______

Tick as appropriate To be achieved within the first week of starting Done N/A

I have been introduced to my Personnel Team

I have signed my joining papers (for payroll)

I have been given the opportunity to have an induction buddy I have discussed the job description and person specification and understand the purpose of my job I have been formally introduced to:

Other members of my team/dept

Head of Nuclear Medicine Service Manager

Lead Clinician for Nuclear Medicine

Other Consultant Colleagues within dept

Key Clinical Staff (list staff)

Key Consultant Colleagues outside of dept

Key Management Staff (list staff)

Divisional Management Team

I have been shown:

The layout of the department

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

40 Staff diningfacilities Area to store refreshments andmake Toilets/cloakroom/rest room facilities point Fire escapes, thelocationoffire pointsandthefire alarm assembly A copy oftheStaffHandbookandstaff policiessummary Reports A current copy oftheorganisation’s Newsletter/Team Briefing Facilities to lockaway my personalbelongings Uniforms I have beenprovided with: number The fire security &emergency The cardiac arrest number I have beenadvisedof: office The locationofthesecurity The locationofthepostroom The equipmentIwillbeusing-computer, medicalequipmentetc. The locationoflinenroom The photocopying facilities The locationoftheresuscitation equipment The locationofthefirstaidbox Bleep system Telephone facilities 41 Section 3 – Staff Aspects of Best of Practice 3–Staff Aspects Section

EANM A copy of the Organisation’s Code of Conduct

An ID Security Badge/Access Swipe Card

Training: I have been given a date to attend:

Fire training

Training in basic life support resuscitation

Training in paediatric life support resuscitation

Manual handling training

The corporate induction programme

Child protection training

Training to receive organisations IT system/s

Profession-specific induction (if provided)

Local induction programme (if provided)

I have been made aware of the following policies/procedures:

Hours of work, rotas, breaks

Salary payment procedures Sickness reporting procedures, sick pay entitlement and medical certificate requirements Annual leave entitlement and booking procedure

Policies and procedures manuals

Fire alarm and fire drill procedure

Data Protection Act and the importance of data quality

Resuscitation guidelines

42 Medicines policy Medicines Personal/patient security andsafety proceduresHealth risks includingprotective clothing managementguidelines Risk Trust policy emailandinternet Waste disposalpolicy policy Equal opportunities Access to medicalrecords protocols: I have beenmadeaware ofthefollowing policies/procedures/ To beachieved withintwo weeks ofstarting Any otherprocedures relevant to thearea (pleaselist): ofwork area policiesaffecting working Regulatory Confidentiality SLAs asrequired) Standard OperatingProcedures/ Level Agreements Service (SOPs/ controlInfection &handwashing Patient care philosophy Waste ofbags disposalprocedure/policy includingtypes Compliments &complaintspolicy Adverse incidentreporting policy amatter ofconcern Raising patientrecordsNew policy 43 Section 3 – Staff Aspects of Best of Practice 3–Staff Aspects Section

EANM Staff benefits/facilities e.g. crèche, staff clubs, fitness centres

Media policy

Learning & development framework

Major incident plan

To be achieved within first month of starting

I have been made aware of the following:

My organizations & team objectives

The Trust’s Performance Management Process

To be achieved within 3 months of starting I have a date when I will meet with my line manager to plan my performance and development objectives I have received a contract of employment

44 Date: Signature ofLineManager: ______Manager’s comments: ______Employee’s comments: completed: Induction Date: ______Department: Start Name: ______Post: ProcessEvidence ofInduction ______Form to beretained inPersonnel File INDUCTION REVIEW FORM REVIEW INDUCTION Sign offsheet APPENDIX 3 45 ______Section 3 – Staff Aspects of Best of Practice 3–Staff Aspects Section

EANM Section 3 – Staff Aspects of Best Practice 3.3. Best Practice for Appraisal Wendy Gibbs and Julie Martin

Good performance management means Managing performance (Phase II ) that people know: During this phase, managers monitor prog- • what they are being asked to achieve ress, provide coaching and feedback to enable individuals to deliver to the best of their ability • what they need to do to improve perfor- and to improve their performance. In addition, mance they discuss career aspirations and agree on individual development plans. • what they need to do to develop themselves Reviewing performance (Phase III ) During this phase, managers review with in- An effective way of achieving this is to ensure dividuals, performance against expectations that, at least once a year, each member of staff in terms of standards, objectives, skills and has the opportunity to discuss with their man- competencies. ager/head of department matters relating to the area they work in or their professional and Structure of the performance planning career development. meeting 1. Reviewing the role profile (job description This can be supplemented by: & person specification) • shorter meetings during the year to feedback on progress to date You will need to review and update the role profile with the individual to ensure they have • team meetings/briefings a clear understanding of the ongoing expectations of their role. Your discussion needs to • mentoring cover:

• regular, less formal feedback • The role purpose.

Planning performance (Phase I ) • Key accountabilities. During this phase, managers agree on the priorities for the coming year with their staff, • Standards of performance. and define the expectations they have for the individual’s performance during the year, in • Skills (e.g. IV skills are required for this post), line with the organisation’s and the team’s knowledge (e.g. Technologist will be asked objectives. to demonstrate knowledge of IV policy), competencies (e.g. to ensure the compe-

46 • • • • • Prepare Yourself andtheEnvironment • • Prepare your Staff for theindividualincomingyear. mance areas which represent the key priorities on a limited number (probably 4-6) of perfor focused be should objectives Performance 3. 2.

Setting Setting performance standards/objectives Confirming the organisation’s plans and organisation’s plans the Confirming Give out performance management pa management performance out Give perwork. at least2/3weeks notice). maceutical administrations. able to inject all adult diagnostic radiophar e.g. within 6 months the individual will be ties ofallclinicalstaff. capabili mix skill increasing e.g. priorities 10IVadministrations). will observe TechnologistChief the achieved, is tency Book aquietroom.Book Agree thelength ofthetimeplanned. Turn offbleep/mobile. No interruptions. phone. Divert Arrange meeting with the individual (give - - - - 47 • • • • • •

Consider the contribution the individual the contribution the Consider Review the standards that apply in the indi potential development objectives. to perform in the job and any gaps. Consider dards/objectives. job. Consider potential stan performance their of part as team the to make could the role description? Update if necessary. vidual’s role. Are they adequately covered in son specification and check it is still current. individual’s role. to relevance consider and priorities and Map outaplanforMap themeeting. Review the individual’s role description/per Identify the skills and competencies needed Look at the organisation’s/team’splans the at Look Section 3 – Staff Aspects of Best of Practice 3–Staff Aspects Section - - - EANM Section 3 – Staff Aspects of Best Practice 3.4. Education and Training Suzanne Dennan

Education and training ensures that Nuclear are unable to employ other European Tech- Medicine Technologists acquire the neces- nologists because their qualifications are not sary knowledge and skills required to become recognised. At present, the education of Tech- competent health care professionals. The tasks nologists in Europe should be in accordance undertaken by Nuclear Medicine Technolo- with European Directive 89/48/CEE, which cre- gists greatly vary from one European coun- ates and monitors the conditions of exchange try to another. Not surprisingly, education for professionals who “have received education schemes for Nuclear Medicine Technologists of at least 3 years’ duration, on a superior level”. also vary considerably between the European countries. Technologists with a 2 year qualification do not fit this criterion. Many countries using the There are two basic models of education: professional school model are now moving to- 1. University-based training: wards university-based training in an attempt – BSc degree after 3 – 4 years to unify the education system of Europe [1]. – MSc degree after 2 years 2. Professional school training: The EANM Technologist’s Committee recog- – 2 – 3 years duration nised that defining the competencies of a – graduates are not awarded a university Nuclear Medicine Technologist was an im- degree. portant step towards a common apprecia- tion of the role of the Technologist. In 1996, Within Europe, there is a lack of harmonisa- the Technologist’s Committee presented a tion of course curricula. For example, course list of competencies for the European Nuclear content, hours devoted to theory and practice, Medicine Technologist. The EANM Entry Level and the delivery of practical training greatly Competencies document is available in the vary. In some countries, unified radiology, Technologist’s section on the EANM web site radiotherapy and nuclear medicine training (www.eanm.org). As the duties and responsi- is provided, in others, nuclear medicine is bilities of Technologists vary nationally and at offered as a separate course. In the univer- a local hospital level, the EANM Competencies sity-based model, training is offered either at are intended to indicate the highest possible undergraduate or postgraduate level. standard of competence. It was envisaged that the Competencies would be helpful for Consequently, the qualifications of Nuclear setting up training programmes around Eu- Medicine Technologists are not internation- rope [2]. ally comparable. Many European countries are experiencing a shortage of Technologists but

48 • • • • • mended by theEANMCompetencies: The following syllabus of education is recom • • • • • • • • • following categories: The EANM Competencies are divided into the

quality controlquality ofradiopharmaceuticals medicine Anatomy, physiology andpathology control protection andquality Radiation Clinical application of radionuclide imaging healthandsafety Occupational protection Radiation Radiopharmacy proceduresRadiotherapeutic Performance ofin-vitro tests Performance ofimaging control withquality Instrumentation organisation Departmental Patient care andwelfare Radiopharmacy including labelling and labelling including Radiopharmacy nuclear of instrumentation and Physics - 49 in teaching. training extra obtain to available portunities teaching methodologies and have limited op gists have not received a formal education in the working Technologists. Usually, Technolo by training practical given are staff new and students departments, many In competent. fully become to required skills necessary the develop not Technologistswill student supervision, and training practical adequate WithoutTechnologist’s education. Medicine Nuclear a of component essential an is ment Practical training in a Nuclear Medicine Depart • • • • The EANM Technologistan The plays Committee eanm.org). (www. site web EANM the of Section ogist’s the Technolin download as available also is effectively. film students teaching EANM The teach to how into insight Technologistsan The aim of this film is to give NuclearMedicine to ask”. wanted to know about teaching but were afraid called, film short a made tee Technologist’sCommitEANM the 2005, In

Case studies service ofaquality Management Research methods Computer technology and image analysis Section 3 – Staff Aspects of Best of Practice 3–Staff Aspects Section “Everything you “Everything - - - - - EANM important role in the education of Technolo- gists in Europe by:

1. Establishing and supporting mechanisms within the EANM to develop the basic training, education and continuing education of Technologists, e.g., the establishment of a PET/CT course at the EANM educational facility.

2. Setting advisory standards for education and training, e.g., the competencies.

3. Supporting and endorsing other organisations providing education and training.

The education and training of Technologists is essential for the professional development of the Nuclear Medicine Technologist. It is important to remember that the student Technolo- gists of today are part of our legacy and reflect on us as well as on future Technologists.

50 edge and skills and develop the personal qual knowl their broaden and improve maintain, Technologists which by means the is CPD life.”[2]working practitioner’s the throughout duties technical and professional of execution the for necessary andthedevelopmentofpersonalqualities skills improvement and broadening of knowledge and CPD is defined as, opment (CPD). professionalcontinuous as devel known ing structured towardsactivity continuous learn of form some be must there that follows It to work. of maintaining a state registration, obligatory part necessary a be will it countries EU some In [1]. competence professional maintain to order in date, to up knowledge professional keep to effort every make Technologiststo Medicine Nuclear on incumbent is It ogists. Technolamong learning continuous sitates changes and increased accountability neces and PET technology, new practices, legislative work. Medicine Nuclear of Theadvancement idly changing environment within which they rap the to adapt to Technologistsneed All Nuclear Medicine Technologist. fundamental to the future development of the is learn to ability the life, of stage any at but be solely associated with school or university, The process of learning is often considered to Suzanne Dennan 3.5. Lifelong Learning andCPD Best of 3–Staff Aspects Practice Section “the “the systematic maintenance, ------51 ally policies will recommend a specific number gists differ between European countries. Usu TechnoloMedicine Nuclear for policies CPD ing CPDrequirements [3]. obligation to assist the Technologist in achiev Ideally employing authorities should have an for in meeting support their CPD obligations. vidual Technologist who will look to employers CPD. Responsibility for CPD rests with the indi of system a implement to body professional the of responsibility the is it Usually patients. gist’s professional standing to employers and Technolothe demonstrate or development Technologist’sthe career assist to serve also membership of a professional body. CPD may the on placed Technologist’stion continuing condi a is CPD countries, European many In therefore lifelong inpractice. learning ities required in their professional lives. CPD is outlined in Table 1. as programme CPD individual their for (PDP) tion plan or a Professional Development Plan ac an devise Technologistindividual should the The Technologist. by learning specific of achievementthe be outcomeshould CPD of the that However,annum. per important is it of CPD points or a minimum number of hours ------EANM Table 1: Professional Development Plan Information

Professional Development Plan (PDP) Information Write down: • all the tasks you perform in your current job, Step 1 • the areas you need to be more knowledgeable about, • the skills you require, • any likely changes to your job within the next year. Step 2 Consider your short and longer-term ambitions and the timescale to achieve them. Step 3 Consider any likely problems or constraints, and the resources available for your learning. Step 4 Start to consider and prioritise your development needs in the light of the above. Step 5 List your CPD priorities for the next year.

It is important that the PDP is regularly re- • Research viewed and updated in line with changes in the Technologist’s current work and their • Publications future plans. CPD activity should represent the personal and professional aspirations set • Imparting knowledge out in the Technologist’s professional development plan. This means that every course, Recording CPD activity: seminar attended by a Technologist is linked The method of recording CPD activity var- to their PDP. ies between European countries. In some countries, the professional body issues each Typical examples of CPD activities: member with an annual CPD record book. • Post-qualification studies CPD activities are recorded in the CPD record book and supported by a personal portfolio of • Short courses evidence of CPD activity (for example, course/ seminar/conference attendance certificates). • Distance learning CPD software programmes are now avail- • Attendance at conferences or seminars able, which automate the management and administration of an organisation’s CPD. • Committee work A major advantage of these CPD software programmes is the provision of an on-line • Quality Assurance recording capability for Technologists. Such

52 enhanced standard ofpatientcare. the by benefits patient the all, of important most and service resultantthe quality higher by benefits employer The performance. of standard higher a enabling Technologistby the benefits CPD life. working her or his out of the Nuclear Medicine Technologist through A commitment to CPD is essential to the work ofits’activities members. more effectively record and monitor the CPD to bodies professional the enables system a - 53 Section 3 – Staff Aspects of Best of Practice 3–Staff Aspects Section

EANM Section 3 – Staff Aspects of Best Practice 3.6. Multidisciplinary Team Working Linda Tutty

A high quality service involves significant mul- resources available to allow for good commu- tidisciplinary teamwork. The multidisciplinary nication within the MDT and with the patient. team (MDT) should provide a framework for A teamwork environment leads to employee continually striving to improve patient care satisfaction, which in turn leads to successful and to produce accurate results in a timescale recruitment and retention of staff. appropriate to the patients’ needs. Staff from many different specialties (ideally possessing Effective teamwork is most likely to occur a variety of skills necessary to produce safe where each team member’s role is seen as and effective patient care) contribute to the essential and where there are clear team goals work in Nuclear Medicine; including doctors, (2). Other factors include effective commu- radiographers, technologists, physicists, phar- nication, recognition of team member’s pro- macists, nurses and administrators. For a Nu- fessional judgment and adequate time and clear Medicine department to run effectively, resources. The Nuclear Medicine team may be all staff need to understand each other’s role aided by having shared education and training within the team and to communicate effec- sessions and by working on team develop- tively. Due to variations of team make-up, each ment. Staff who work best in a team are not department should produce its own docu- only capable of performing their own role but ment outlining each member’s role. also possess the knowledge, skill and attitudes that support their team (3). Multidisciplinary teamwork is an approach designed to guide thinking and practice in MDT work is influenced by organisational the healthcare system. Characteristics such as culture. A concise organisational philosophy objectivity, regularity, common goals, efficien- on the importance of teamwork can promote cy, a patient perspective and shared respon- collaboration by encouraging new methods sibility are required. In the decision-making of working together. Teams require training to process, each professional has a responsibility learn how to work together and understand to contribute their skills and to acknowledge the role of each member. They also require an the goals of the department. Members of the effective administrative structure and leader- Nuclear Medicine team should have their role ship. well defined and understood. There should be clarity and accountability in the team. Stud- The single best way to promote a teamwork ies have shown that when staff feel they are environment is through open, prompt and an integral part of the multidisciplinary team, constant communication. Collaboration their stress levels are reduced allowing for bet- enhances teamwork (4). Collaboration is a ter patient care (1). There should be sufficient process that requires relationships and inter-

54 cardiology, oncology, paediatrics, neurology, paediatrics, oncology,cardiology, endocrinology,as such areas specialist some there may be regular clinical commitments to hospitals, most In important. is departments other with liaison close so areas, specialty er Nuclear Medicine can provide services to oth • • • be classifiedas: within the Nuclear Medicine department may The benefits of the multidisciplinary teamwork • • • • discuss: part of the team. The MDT should periodically as themselves perceive they not or whether of regardless professionals between actions

Nuclear Medicine equipment and diagnos each profession fective service service audits basedonquality ports cies tic/therapeutic needs Turnaround times of procedures and re and procedures of times Turnaround Staffing needs, concerns and competen and concerns needs, Staffing A more clinically effective and/or cost ef cost and/or effective clinically more A Quality processes to resolve problem areas More satisfying roles or career paths for paths career or roles satisfying More patient-centred and responsive more A - - - - - 55 Medicine service. service. Medicine maintain an efficient and high quality Nuclear tion, a multidisciplinary team helps create and collabora successful With techniques. cine tions and for further developing Nuclear Medi applica research for requisite necessary a is In addition, such a multidisciplinary approach patient managementisachieved. optimum that ensure to held are meetings MDT Medicine Nuclear regular that essential is It provision. service cost-effective for able volvement in cross-specialty meetings is valu In malignancies. complex of management enhanced for allows care cancer of delivery the in conferences team multidisciplinary of participation The disease. thyroid malignant and benign of treatment the in docrinology en with discussion close maintain therapy ample, departments that provide radionuclide ex For (6). (5) orthopaedics and nephrology Section 3 – Staff Aspects of Best of Practice 3–Staff Aspects Section ------EANM References

Section 1 2.3 1.3 References Further reading 1. Otte A, Maier-Lenz H, Dierckx RA. 2005. Good clinical Bailey D. The NHS Budget Holder’s Survival Guide. 1998. practice: Historical background and key aspects. Nuc Med http://www.rsmpress.co.uk/bkbailey.htm Comm. 26(7):563-574. 2. Corrao S, Arnone G, Arnone S, BaldarI S. 2004. Medical 1.4 ethics, clinical research, and special aspects in Nuclear Me- Further reading dicine. Q J Nucl Med 48:175-179. Institute of Physics and Engineering in Medicine. A good practice guide on all aspects of ionising radiation protection 3. Emanuel EJ, Wendler D, Grady C. 2000. What Makes Clini- in the clinical environment. Medical and Dental Guidance cal Research Ethical? JAMA.283(20):2701-2711. notes. 2002. 4. Bacher K & Thierens HM. 2005 Accurate dosimetry: an Sharp PF, Gemmell HG, Smith FW. Practical Nuclear Medici- essential step towards good clinical practice in Nuclear ne, 3rd edn. UK: Oxford University Press, 2005. Medicine. Nuc Med Comm. 26 (7):581-586. 5.Bourguignon MH. 2000. Implications of ICRP 60 and the 1.5 patient directive 97/43/Euratom for Nuclear Medicine. Q J Further reading Nucl Med. 44(4):301-9. http://www.bnms.org.uk/members/members.asp 6. De Vos FJ, De Decker M, Dierckx RA. 2005. The good labo- 1.6 ratory practice and good clinical practice requirements for the production of radiopharmaceuticals in clinical research. Further reading Nuc Med Comm 26 (7):575-579. http://www.dh.gov.uk Further reading 1.7 Council Directive 97/43/EURATOM of 30 June 1997 on Further reading health protection of individuals against the dangers of http://www.bnms.org.uk ionising radiation in relation to medical exposure, and re- pealing Directive 84/466/EURATOM. Official Journal of the Section 2 European Communities L-180/22, 09/07/97.

2.2 European Commission – Directorate-General, Environment, Further reading Nuclear Safety and Civil Protection. Radiation Protection 99: EU Guidance Document Radiation Protection 100. Guidance Guidance on Medical Exposures in Medical and Biomedical for protection of unborn children and infants irradiated due Research;1998. to parental medical exposures. 1998. Good Manufacturing Practices for Pharmaceutical Pro- http://ec.europa.eu/energy/nuclear/radioprotection/pu- ducts: Main Principles. WHO Technical Reports, Series No blication/doc/100_en.pdf 908, 2003.

EU Guidance Document Radiation Protection 118: Referral Good Manufacturing Practices for Sterile Products. WHO Guidelines for Imaging. 2000. Technical Reports, Series No. 902, 2002. http://ec.europa.eu/energy/nuclear/radioprotection/pu- International Commission on Radiological Protection. Pro- blication/doc/118_en.pdf tection of the Patient in Nuclear Medicine. ICRP Publication 52, Annals if the ICRP, 17(4). Oxford: Pergamon Press; 1987. Royal College of Radiologists. Making the best use of a De- partment of Clinical Radiology. 5th edn. 2002. International Commission on Radiological Protection. Ra- diation Dose to Patients From Radiopharmaceuticals. ICRP http://www.rcr.ac.uk/index.asp .

56 literature. The College 2001;7:43-53. ofRadiographers 3. Gibbs V. Learning how to a learn: selective review of the Professional 2003. Development. 2. The College of Radiographers. A Strategy for Continuing The College2003;9:99-107. ofRadiographers tures: their impact on the development of lifelong learners. 1. Sim J, Zadnik MG, Radloff A. University and workplace cul References 3.5 php?navId=31 http://www.eanm.org/brochure/tech_brochure. tencies, 1996. Compe Level Entry Technologist’sEANM Committee, 2. 2002; 29:8. Medicine Nuclear of Journal European countries. ropean Eu in training Technologist Medicine P.Nuclear Lass 1. References 3.4 Hall, 2005. Prentice Times Financial Harlow, edn. 6th ment, Manage Resources Human TaylorS. L, Hall D,Torrington Further reading 3.1, 3.2and3.3 3 Section 611. Geneva: WHO; 1977. series Report TechnicalPurposes. Non-medical and ning Radionuclides on Human Beings for Medical Research, Trai and Radiation Ionising of Use Organisation. Health World Press, 1991. Pergamon Oxford:ICRP, 22(3). the of Annals 62, blication Pu ICRP Research. Biomedical in Protection Radiological Protection. Radiological on Commission International ICRP, 28(3).Oxford: Pergamon Press; 1998. – Addendum to ICRP 53.ICRP Publication 80, Annals of the Radiopharmaceuticals From Patients to Dose Radiation Protection. Radiological on Commission International mon Pres; 1987. PergaICRP,Oxford: the 18(1-4). of Annals 53. Publicatoin 3 ------57 Eur J Nucl Mol Imaging.Eur 31(4):605-12. JNuclMol ging cases in thyroid approach. a cancer: multidisciplinary 6.Tuttle M, Robbins R, Larson SM, Strauss HW. 2004. Challen denectomy. Cancer Treat Res. 127:253-67. lympha sentinel selective for team multidisciplinary a as of Nuclear Medicine physicians, surgeons, and pathologists Credentialing 2005. al. et H Y, FujiiKitagawa M, 5.Kitajima JNursManag. 4 (2):93-101. lity? teamwork-4. Rowe myth H. 1996. Multidisciplinary or rea development. Sairaanhoitaja. (8):32-4. health services 3. Merjola-Pertanen T. 1993. teamMultidisciplinary work in 2000 ship. edition.Mosby: Sixth Leader and Management Nursing to 2.TomeyGuide AM. Care.10: 65-66. Health in Quality between. in everything and bad, good, the teamwork: Multidisciplinary 2001. J. 1.Firth-Cozens. References 3.6 - - - - EANM Imprint

Publisher: European Association of Nuclear Medicine Technologist Committee and Technologist Education Subcommittee Hollandstrasse 14, 1020 Vienna, Austria Tel: +43-(0)1-212 80 30, Fax: +43-(0)1-212 80 309 E-mail: [email protected] URL: www.eanm.org

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Chapter 1 References 1. Nishimura S, Mahmarian JJ, Boyce TM, Verani MS. Quan- titative thallium-201 single-photon emission computed tomography during maximal pharmacological coronary vasodilation with adenosine for assessing coronary artery disease. J Am Coll Cardiol 1991;18:736-745.

2. Varma SK, Watson DD, Beller GA. Quantitative comparison of thallium-201 scintigraphy after exercise and dipyridamole in coronary artery disease. Am J Cardiol 1989;64:871-877.

3. Dilsizian V, Rocco TP, Strauss HW, Boucher CA. Techne- tium-99m isonitrile myocardial uptake at rest. I. Relation to severity of coronary artery stenosis. J Am Coll Cardiol 1989;14:1673-1677.

4. Borges-Neto S, Shaw LK. The added value of simultane- ous myocardial perfusion and left ventricular function. Curr Opin Cardiol 1999;14:460-463.

5. Iskandrian AS, Chae SC, Heo J, Stanberry CD, Wasserleben V, Cave V. Independent and incremental prognostic value of exercise single-photon emission computed tomographic (SPECT) thallium imaging in coronary artery disease. J Am Coll Cardiol 1993;22:665-670.

6. Bonow RO, Dilsizian V. Thallium-201 for assessing myocardial viability. Semin Nucl Med 1991;21:230-241.

7. Holman ML, Moore SC, Shulkin PM, Kirsch CM, English RJ, Hill TC. Quantification of perfused myocardial mass through thallium-201 and emission computed tomography. Invest Radiol 1983;4:322-326.

8. Udelson EJ, Coleman PS, Metheral J, et al. Predicting re- covery of severe regional ventricular dysfunction. Compa- rison of resting scintigraphy with 201Tl and 99mTc-sestamibi. Circulation 1994;89:2552-2561.

9. Sciagrà R, Santoro GM, Bisi B, Pedenovi P, Fazzini PF, Pupi A. Rest-redistribution thallium-201 SPECT to detect myocardial viability. J Nucl Med 1998;39:385-390.

10. Pace L, Perrone Filardi P, Mainenti PP, et al. Identification of viable myocardium in patients with chronic coronary artery disease using rest-redistribution thallium-201 tomography: optimal image analysis.J Nucl Med 1998;39:1869- 1874.

11. Cuocolo A, Acampa W, Nicolai E, et al. Quantitative thallium-201 and technetium-99m sestamibi tomography at rest in detection of myocardial viability and prediction of improvement in left ventricular function after coronary revascularization in patients with chronic ischaemic left Eur e ventricularopea dysfunction. J Nucl Cardiolicin 2000;7:8-15. n Association of Nuclear Med