MEDICAL IMAGING DEPARTMENT POLICY AND PROCEDURE MANUAL Page 1 of 3

Originally Adopted: 3/2010 Policy Number Last Reviewed: 5/11

Last Revised: 5/11 3002 Title: Procurement, Storage, and Administration of Contrast Media

Originating Department: MEDICAL IMAGING Scope: ALL STAFF DIRECTOR OF MEDICAL Responsible Person: IMAGING SERVICES

PURPOSE:

Establish a guideline to promote the safe and effective administration of contrast media via intravenous, oral, rectal, and radionuclides with concomitant exceptions used for imaging studies.

POLICY:

The goal of radiologists and other personnel administering intravascular contrast media should be to utilize these agents appropriately and properly so that imaging studies are optimized and risk to the patient is minimized.

PROCEDURE:

Procurement and Storage:

Radiographic contrast media shall be ordered by the Pharmacy Department. All contrast media shall be stored in the Department of Imaging Services in a secured area at room temperature with limited access.

Contrasts kept in the warmer, a log will be kept and monitor daily to ensure that the warmer is functioning properly – temperature range should be between 36°C to 46°C. If out of compliance, a call will be place to Biomed and all contrast are removed from that warmer. The CT Tech will check the warmer daily to ensure that it is working properly. At the end of the month, the log will be sent down to Pharmacy.

A sticker with the date will be place on each contrast bottle prior to placing the bottle in the contrast warmer. The contrast bottle should be discarded if it is not used at the end of 30 days.

Pharmacy staff will check for expiration dates once a month.

Administration of Intravascular Contrast Media

The American College of Radiology (Res. 38) approves the injection of intravascular contrast media by licensed radiology technologists and radiologic nurses under the direction of a radiologist or ER physician who is personally and immediately available.

Prior to administration of contrast media the following steps must be performed: 1. Request for the study must be in writing from a licensed independence practitioner with sufficient information to demonstrate the medical necessity of the examination. 2. Signed informed consent obtained. 3. Appropriate Lab results must be available for review. 4. Patient should be screened for any contraindications. 5. Patient identified by using two identifiers.

Administration of Oral/Rectal Contrast

Oral/rectal contrast must be ordered by licensed independence practitioners, and administered only by qualified healthcare personnel including but not limited to radiologists, physicians, technologists, nurses (RN, LVN), etc.

DEPARTMENT OF MEDICAL IMAGING Policy Number POLICY & PROCEDURE MANUAL Page 2 of 3 3002

Title: Procurement, Storage, and Administration of Contrast Media

Administration of contrast media dosage will be dependent on patient’s weight and will be recorded at time of study.

NOTE: Technologists have been instructed to have a same sex member (employee or family member) present whenever inserting an enema tip in a patient of an opposite sex.

Patient will be monitored while receiving contrast media by staff sufficiently trained to recognize and respond to a significant reaction or adverse event.

Contrast media is considered to be a medication. As such, any incidence of an error or adverse reaction will be reported in accordance with the established Centinela Hospital Medical Center policy.

All medication containers, on and off the sterile field, will be kept in the procedural room until the conclusion of the procedure. At the end of the procedure, all labeled containers on the sterile field will be discarded.

The above policy is not relevant to the injection of radionuclides in nuclear imaging. These may be injected by a technologist, who is certified and trained in performing nuclear imaging.

At the time of scheduling, staff will determine if patient is diabetic and taking either of the following medications or Metformin containing drugs: (Actoplus Met, AvandamerAvandamet, Fortamet, GlocophageGlucophage (FM), Glucophage XR, Glucovance (glyburide/metformin), Glumetza, Glycon, Janomet, MegaglipMetaglip (glipizide/metformin), MetforminRiomet, Metformin) and is instructed to discontinue on the day of their exam unless instructed otherwise by their physician. If a patient is taking any of the above medications on the day of the procedure, a BUN/CREAT will be done post procedure. The result will be reviewed by the Radiologist or Radiology nurse.please refer to the Discharge Information for Patient Taking Metformin policy. The Radiologist will inform the referring physician for follow-up for any abnormal results.

Upon completion of the exam and administration of IV contrast, patients are advised NOT to resume their medication for 48 hours. Patients are advised to contact their physicians to determine if a substitute medication is needed.

Title: Procurement, Storage, and Administration of Page 3 of 3 Contrast Media ATTACHMENT {A}

Exam Adm. Route Contrast Name Amount

CT Isovue 370 / Radiologist’s CT Scans with contrast IV Non Ionic Visipaque discretions Isovue 370 / Radiologist’s CTA Scans / Run-Off IV Non Ionic Visipaque discretions Gastrografin / Gastrografin / Barium Radiologist’s CT Abd without contrast Oral Barium Sulfate Sulfate discretions Radiologist’s CT Sialogram Ductal via Cath Sinografin discretions

Radiology Radiologist’s Barium Enema Rectal Barium Barium discretions Radiologist’s Gastrograffin Enema Rectal Gastrografin Gastrografin discretions Barium Sulfate / Radiologist’s UGI / SB Barium Oral / NG Barium Gastrografin discretions Non Ionic / Radiologist’s IVP IV Isovue 300 Ionic discretions Non Ionic / Radiologist’s ERCP Ductal via Cath Isovue 300 Ionic discretions Radiologist’s Cystogram/Urethrogram Foley Ionic Cystografin discretions Radiologist’s Video Esophagram Oral Barium Barium Sulfate discretions Radiologist’s Hysterosalpingogram via Cath Ionic Sinografin discretions

Special Procedures Non Ionic / Radiologist’s Myelogram Spinal Isovue M-200/300 Ionic discretions Non Ionic / Radiologist’s Discogram Spinal Isovue M-200/300 Ionic discretions Non Ionic / Radiologist’s Sinogram/Fistulogram Ductal via Cath Isovue 300 Ionic discretions Isovue 300 / Radiologist’s Venograms IV Non Ionic Visipaque discretions Isovue 300 / Radiologist’s Angiograms IV Non Ionic Visipaque discretions Non Ionic / Radiologist’s Arthrograms Joint Space Isovue 300 Ionic discretions Radiologist’s Sialogram Ductal via Cath Ionic Sinografin discretions

MRI Radiologist’s MRI with contrast / MRA IV Non Ionic Multihance discretions