4. STANDARD: OUTPATIENT ANGIOGRAPHY.
A. Output angiography is now considered safe and feasible for many patients if appropriate precautions are taken. This represents significant cost savings as well as greater convenience for patients and health care providers.
(1) Definition of Outpatient Angiographic Procedures. The following procedures can be considered for outpatient angiographic study:
Abdominal aortography
Peripheral [runoff] arteriography
Thoracic aortogrpahy
Renal and mesenteric arteriography
Head and Neck arteriography
Selective extremity arteriography
Pulmonary arteriography
Selective catheter venographic studies (i.e., renal venography, gonadal venography, and testicular vein embolization)
Other angiographic studies may be considered for out patient procedures if deemed medically appropriate.
(2) Patient Selection. Patients considered as candidates for outpatient angiographic procedures should meet the following criteria:
(a) A medical history should be available including indications for procedure, list of current medication, allergies, and prior relevant surgical procedures.
(b) The patient must have arrangements made for transportation home, preferably with a family member or a neighbor, rather than by taxi or in the company of someone unfamiliar with the patient. Due to medications administered during the procedures, it is necessary that the patient not transport himself/herself home, and
(c) The patient or family member should be able to arrange for the patient's care after the procedure; i.e., due to sedation used during the angiographic procedure, the patient should not be left unattended. If the patient lives alone, it is preferable for a family member or neighbor to attend the patient for at least 8 hours after the time of discharge, and
(d) The patient's mental status should be intact; confused or impaired patients should be strongly considered for an inpatient procedure unless careful arrangements can be made for close observation post-procedure.
B. Relative Contra-Indications to Outpatient Angiography
Patients with any of the following are considered at increased risk for outpatient angiography and an inpatient procedure may be indicated:
(1) Poorly controlled hypertension (i.e., diastolic pressure greater than 100 mm/Hg) as these patients have a higher incidence of hematoma and bleeding complications at groin puncture sites.
(2) Abnormal renal function because of the potential for further deterioration of renal function after exposure to contrast media.
(3) Abnormal coagulation parameters, electrolyte. abnormalities or significant anemias.
(4) Advanced age (greater than 75 years) because of the potential for increased complications. Older patients may be considered appropriate candidates for outpatient angiographic procedures, but only after careful scrutiny of the other criteria. If there are no other significant organ system abnormalities and the patient has a responsible adult available for observed care post-procedure, outpatient angiography may be appropriate.
(5) When observation by a responsible adult cannot be satisfactorily arranged post-discharge from the outpatient procedure.
(6) Travel time greater than one hour from the outpatient angiographic facility; these patients may be studied on an outpatient basis but should be encouraged to arrange an overnight stay close to the facility or nearby hospital to allow for prompt management of delayed complications should they occur.
(7) Diabetics are not necessarily excluded from outpatient procedures; however, caution should be taken to insure that their renal function is normal, that they are satisfactorily hydrated prior to and post-procedure, and that appropriate arrangements for insulin management are made prior to the procedure.
C. Patient Care
The following are offered as minimal guidelines for patient care related to outpatient angiographic. procedures. Regardless of the setting, all angiographic procedures should conform to usual and accepted techniques.
(1) Pre-procedure Care
(a) The clinical history should be reviewed by the physician to insure that the indications for the study are appropriate. Prior angiographic and other pertinent radiographic studies should be reviewed. In patients undergoing peripheral vascular evaluation, initial assessment with noninvasive studies with recording of ankle and brachial pressures is recommended.
(b) List of current medications should be available; the patients should be encouraged to bring their medications with them.
(c) Appropriately documented informed consent should be obtained.
(d) Initial assessment should include recording of vital signs, assessment of peripheral pulses and review of laboratory parameters.
(e) Laboratory evaluation may be appropriate as medically indicated and this may include hemoglobin, hematocrit, creatinine, electrolytes and coagulation parameters.
D. Procedure Care
(1) All arteriographic patients who are at high risk should have cardiac monitoring throughout the procedure.
(2) All arteriographic patients should have intravenous access maintained throughout the procedure for administration of medications and fluid resuscitation.
E. Post-procedure Care
(1) Patients with arterial catheterization should be monitored for a minimum of four hours after the procedure. All patients should have post-procedure monitoring of vital signs, assessment of puncture site and distal pulses. Patients undergoing head and neck arteriography also should have monitoring of neurologic function. Monitoring should be increased to six hours in patients with hypertension, or those with a hematoma post-procedure.
(2) Assessment prior to discharge should include evaluation of puncture site, distal pulses and vital signs. Vital signs and pulses should be unchanged from the time of admission; any significant change precludes discharge. The patient should be evaluated by the angiographer or designated nurse/technologist prior to discharge. The patient should be ambulated and the puncture site checked for bleeding and hematoma prior to discharge.
(3) A physician should be available to handle patient problems or questions for 24 hours post-procedure.
(4) Access to inpatient care should be available for patients who have unexpected complications or require further procedures at the completion of the angiographic study.
F. Communication
(1) Any results which mandate immediate intervention or treatment by the responsible physician necessitate direct and immediate verbal communication between the radiologist and the responsible physician. This should be documented.
(2) Reporting of less urgent findings may be communicated by indirect means such as mail, recorded messages, computer print outs or FAX. In every instance the time it takes to transfer information shall not unreasonably delay the treatment of a condition specifically diagnosed on the angiogram. The report should be documented in the X-Ray record.
G. Indications for Admission
The decision to admit a patient after an outpatient angiographic procedure is at the discretion of the physician. The following should be considered as indications for admission.
(1) Complication resulting from the angiographic procedure including any significant change in pulse in the affected extremity, neurologic changes, persistent bleeding, or persistent nausea and vomiting post-procedure; or
(2) Significant findings on diagnostic angiography warranting further therapy that would necessitate inpatient admission is also a reasonable indication for admission; or
(3) Admission at the time of the study is encouraged if problems are suspected or arise.
H. The Angiographic Facility
(1) The highest possible quality imaging equipment should be available for all outpatient angiography procedures. This should include high resolution image intensifier, television chain and standard arteriographic filming capabilities to include rapid serial films of at least 14 inches in diameter. Digital subtraction capabilities are highly desirable as they allow decreased contrast volumes and less cardiovascular disturbances during angiography.
(2) There must be adequate facilities for cardiac monitoring and for cardiac resuscitation.
(3) Every angiographic facility should have the appropriately trained personnel to provide proper patient care and operation of the equipment.
I. Quality Improvement
Outpatient procedures should be monitored as part of the overall quality improvement program of the facility. Incidence of complications and unexpected admissions should be recorded and periodically reviewed for the opportunity to improve care. The incidence of delayed admission (i.e., admissions that become necessary after discharge from the outpatient facility) should be less than 21 for problems or complications related to angiography. This data should be collected in a manner which complies with statutory and regulatory peer review procedures in order to protect the confidentiality of the peer review data.
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