Download File - Theoretical Base for Practice

Running head: PREGNANCY TESTING FOR WOMEN
Pregnancy Testing for Women of Child-Bearing Age Prior to Medical Imaging
Tim Bedell, Sabrina Carlson, Nancy Harroun, & Susan Heinlen
Ferris State University
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Pregnancy Testing for Women of Child-Bearing Age Prior to Medical Imaging
Even though a fetus is protected by many of the harmful elements from the outside world
from its mother, many things can still harm the fetus and cause birth defects or even spontaneous
abortion. Teratogenic (harmful to a fetus) substances include alcohol, recreational drugs, some
prescription medications, and even over-the-counter medications and vitamins (University of
California San Francisco, 2015). Women must be very careful when using any of these
substances to prevent harming their unborn child. One teratogenic substance that many women
do not think of is radiation. This can come in the form of ingested or inhaled radioactive
materials or radiation from diagnostic procedures (CDC, 2011). Guidelines and policies differ
greatly from facility to facility and no national guidelines exist for screening women of child
bearing age for pregnancy prior to radiologic exams (Department of Radiology, Indiana
University School of Medicine, 2007). With greater use of radiology in healthcare, it seems that
standardized guidelines should be developed to ensure women do not expose their fetuses to
unintentional doses of radiation. This paper examines the importance of pregnancy screening
and education of women who require radiologic studies.
Clinical Need
Female patients of child-bearing age, who present to the emergency department for a
medical evaluation, may not routinely be offered urine pregnancy testing when presentation does
not indicate the need. In many cases, the reason for the visit may not warrant the test. For
example, an extremity injury, a cough, fever, foreign body in the eye, rash, sore throat, or an
asthma flare will not necessarily flag for pregnancy screening. These problems may be treated
without the need to establish pregnancy status; however, patients needing radiology studies may
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present the clinical need for pregnancy status to be assessed. The literature addressing the
appropriateness of establishing pregnancy in women of child-bearing age (including adolescents
who are menstruating) for radiological procedures, describes the inclusion of “the mother in the
decision-making process whenever possible” (Toppenberg, Hill, & Miller, 1999, p. 2).
According to a radiodiagnostic imaging study in Ontario, data collected from 1991 to 2008 of
exposed and unexposed mothers, “offspring of women exposed to major radiodiagnostic testing
in pregnancy do not appear to be at higher risk of childhood malignancy than the children of
unexposed mothers” (Ray et al., 2010). Although, the American College of Radiology reassures
that “no single diagnostic procedure results in a radiation dose that threatens the well-being of
the developing embryo or fetus” (Toppenberg et al., 1999), the CDC states that there could be
severe health consequences for the fetus even at radiology doses too small to make the mother
sick (CDC, 2011). With that, there is still perceived risk by the patient warranting further
clarification. Radiation exposure is measured in rad, with the acceptable cumulative fetal dose
being 5 rad. To add perspective, an extremity x-ray emits 0.001 rad per film; this means that a
pregnant mother would have to have 5,000 upper or lower extremity x-rays to expose her fetus to
the accepted 5 rad (Toppenberg et al., 1999). Further, a two view chest x-ray is 0.00007 rad, so
the mother would have to have 71,429 chest x-rays to reach that limit (Toppenberg et al., 1999).
While the exposure and risk are minimal, a woman of childbearing age should be informed, to be
able to decide if she would like a urine pregnancy test prior to the study. The American College
of Obstetricians and Gynecologists follow that “women should be counseled that x-ray exposure
from a single diagnostic procedure does not result in harmful fetal effects…” (Toppenberg et al.,
1999). In order to establish “proactive risk reduction [which] prevents harm before it reaches the
patient” (The Joint Commission, TJC, 2015), the process of screening for pregnancy in the
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emergency department for all radiographic procedures, including offering a urine pregnancy test
if a female patient indicates there is a chance of pregnancy, should be considered. Understanding
that “…birth anomalies frequently occur spontaneously, with no identifiable cause,” females
who may be pregnant should still be informed of the risk, as “proper communication may also
reduce unnecessary litigation in the event of an unexpected outcome” (Toppenberg et al., 1999).
Risk management is utilized to evaluate for potential financial losses related to “malpractice…or
negative public relations” (Yoder-Wise, 2015). By formulating a team to collect data on the
prevalence of pregnancy screening, opportunities for pregnancy testing, as well as safety
counseling techniques in the emergency department prior to radiographic procedures on females
of childbearing age, we can work together to “correct process problems in order to reduce the
likelihood of experiencing adverse events” (The Joint Commission, 2015, p. 14).
Interdisciplinary Team
Establishing a multidisciplinary team to collect data, establish goals, identify and
implement a plan, and evaluate the results is crucial to the quality improvement (QI) process.
Since the “QI team members should represent a cross section of workers who are involved with
the problem” (Yoder-Wise, 2015), it is important to include staff who have knowledge of the
specialties this particular problem encompasses. The team should include insight from a
radiologist, obstetrician (OB), emergency room (ER) physician, ER nurse, ER nurse supervisor,
radiology technician, radiology supervisor, laboratory technician or supervisor, and a QI nurse.
The concepts provided by their expertise will help in the QI process for the necessity of
pregnancy screening, testing, and educating patients with regard to radiologic studies in the
emergency department.
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Data Collection Methods
The data collection method to be used for this quality improvement process is the A3
model. This model utilizes an 11 x 7 inch piece of paper to develop a problem solving approach
to identify gabs between the current condition and the ideal condition (Pelletier, L., n.d.). Key
stakeholders are involved in identifying what this current condition is and where it should be.
The fishbone chart is one part of the A3 model and is used to identify possible causes for the
problem (Pelletier, L., n.d.). Some causes for inconsistent urine pregnancy screening practices
prior to medical imaging in the emergency department that were identified were inconsistent
processes due to lack of a standard protocol, lack of education for practitioners and radiology
technicians, and lack of counseling for patients. This model can also be used to expand on who,
what, when, where, how often and consequences of this problem (Pelletier, L., n.d.). The root
causes are then identified by the stakeholders in order to identify the real problems, not just the
contributing factors so they can be fixed (Pelletier, L., n.d.). Data can also be obtained by using
a Pareto chart, which is a vertical bar graph, which helps identify what problems have the highest
frequency and should be addressed first (Pelletier, L., n.d.). Data for the Pareto chart would be
collected by abstracting when pregnancy tests are ordered for medical imaging in order to
address the instances when this is occurring most often. This data would then be used to identify
when pregnancy testing was ordered for tests that would not necessarily need a pregnancy test or
instances where the patient could have been shielded with a lead apron protecting the abdomen
from radiation instead of pregnancy testing.
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Outcomes
The ultimate goal would be to reduce unnecessary pregnancy testing prior to radiological
imaging for women of childbearing age in the emergency setting. There is no set standard for
when pregnancy testing should be done prior to medical imaging so another goal would be to
have a standard protocol for all emergency patients of childbearing age requiring medical
imaging (World Health Organization, 2008). The third goal would be to have a scripted safety
counseling process for helping women of childbearing age decide if they want a pregnancy test
prior to medical imaging (The Joint Commission, 2015, p. 14).
Implementation
Various implementations can be initiated to minimize unexpected exposure of a fetus to
radiation by identifying pregnant females quickly and effectively prior to diagnostic radiation
procedure. A good assessment is key to identifying whether radiology procedures are appropriate
for female patients. Implementing a scored electronic pregnancy screening tool to help identify
pregnant females is a good first step assessment tool. This could be initiated as an electronic task
for females who have certain diagnostic tests ordered or as a task for all women receiving
treatment in the emergency department. This screening tool would allow a nurse to make
appropriate selections specific to their patient to identify whether pregnancy testing should be
completed prior to radiology procedures and would be available for radiologist and technicians
to refer to. This screening tool would collect patient information such as: is the patient of child
bearing age, when the patient had their last period, if the patient has regular periods, are they
sexually active, are they using any form of birth control, have they had a hysterectomy, have
they gone through menopause, was a pregnancy test completed and if so when and what were the
results, and a selection of specific radiology exams to be performed especially if the exam would
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expose the patient to radiation of 50 rad or greater, which has potential for greater risk to a fetus.
The nurse would make selections appropriate for the patient in this screening task. Completion of
this task would help identify patients that may require a pregnancy test prior to a procedure if it
has not been done already, those that require special consideration by doctors, and those that can
proceed without further concern for fetal harm. Implementation of radiology testing protocols
based on the score of this screening tool should also be established. If a pregnancy screening
score places a female patient at moderate to high risk of being pregnant, or as pregnant, the
radiology protocol should be to delay the test, use added precautions such as shielding the pelvis
with a lead apron, avoid scanning the pelvic area, or use low dose radiation, less than 5 rad, to
minimize risk to a potential or existing fetus, or further consult with the attending doctor to
establish an appropriate plan of care (American College of Radiology, 2014).
Evaluation
Evaluation will help identify if implementation of the pregnancy screening tool
effectively identifies previously unknown pregnancies in female patients prior to radiology tests
and if establishing a radiology protocol for pregnant or potentially pregnant patients provides
consistent patient care. Initial evaluation of the pregnancy screening tool must identify if this tool
accurately identifies women who should have a pregnancy test prior to a radiology test. This can
be done by collecting data on the number of pregnant females identified through the use of the
pregnancy screening tool. Tracking the percent of unknown pregnancies identified in the first six
months following implementation of the pregnancy screening tool compared to the percent of
pregnancies identified in the six months prior to the use of the screening tool will help establish
whether this tool is less effective, as effective, or more effective at identifying unknown
pregnancies. Identifying what radiology procedures and testing precautions were implemented
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for pregnant patients would make it possible to track whether radiology protocol was followed
with pregnant patients and if following protocol minimized radiation exposure to a potential or
existing fetus based on the established protocol.
Conclusion
Pregnancy and the birth of a child should be a joyous time filled with love and
excitement. All efforts should be made to avoid complications during pregnancy and undue
harm to the fetus. While risk to the fetus is low from routine radiological examinations, there is
still a risk of harm and women should be aware of this. There is also the fact that many women
do not know they are pregnant until well into the pregnancy. Fetal vulnerability to radiation
varies throughout the pregnancy, but is most harmful between weeks two and eighteen (CDC,
2011). Routine screening of women that show a high risk of being pregnant would help health
care providers choose diagnostic exams with greater care with knowledge of a woman being
pregnant. The mother would also be able to allow or deny radiological exams based on the new
information of her pregnancy.
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References
American College of Radiology. (2014). ACR-SPR practice parameter for imaging pregnant or
potentially pregnant adolescents and women with ionizing radiation. Retrieved from
http://www.acr.org/~/media/9E2ED55531FC4B4FA53EF3B6D3B25DF8.pdf
Bentur, Y., Koren, G., and Ratnapalan, S. (2008). Doctor, will that x-ray harm my unborn child?
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Department of Radiology, Indiana University School of Medicine. (2007). Pregnancy screening
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http://www.ncbi.nlm.nih.gov/pubmed/17660116
Pelletier, L. (n.d.). “A3”-The basic problem solving tool. Retrieved from
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Ray, J. G., Schull, M. J., Urquia, M.L., You, J. J., Guttmann, A., & Vermeulen, M. J. (2010).
Major radiodiagnostic imaging in pregnancy and the risk of childhood malignancy: A
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Toppenberg, K. S., Hill, A., Miller, D. P. (1999). Safety of radiographic imaging during
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