IRSA Credentialing Guidelines

IRSA Guidelines for Credentialing for Interventional Radiology

Introduction

Traditionally, interventional radiology has been regarded as an integral part of radiological practice, with any doctor gaining the F.R.A.N.Z.C.R. or equivalent qualification considered competent to practice the full gamut of interventional procedures. The last 10 years have seen an almost exponential increase in the number and complexity of minimal invasive therapeutic or biopsy procedures that require radiological guidance. All trainee registrars have considerable exposure to interventional radiology in addition to College requirements for angiography, nephrostomy, abscess drainage and biopsy.
However while they may have performed many complex procedures as first operator, there is no doubt that additional training is required for those wishing to perform the more complex interventional procedures.
The radiology community is ready and able to train medical graduates who are willing to make a 5-year commitment to learning the skills required. However we refuse outright to offer superficial or limited training to those who wish to indulge in invasive radiology procedures. Unless one understands all aspects of radiologic practice, it is not acceptable or responsible to try and perform one small aspect of it in a vacuum.

Credentialing

Credentialing is the process by which physicians are determined by hospitals to be competent and are permitted to perform procedures. The granting of credentials is designed to protect patients from persons with superficial training in imaging and maintain quality of care. Patients are not in a position to know which physicians are best qualified to perform which procedures. Patients place their trust in the hospital to screen physicians based on training and competency, not on their ability to refer patients to the hospital.

Training

The primary requisite for an interventional or endovascular radiologist is that they must be fully trained in all aspects of imaging.

Specialist interventional radiologists will require additional training in this sub-specialty. This will consist of one year of approved full-time instruction in interventional radiology at an approved site. Logbook documentation of which procedures have been performed is required. The documentation must allow for independent verification of the work done and indicate for which procedures the trainee was the primary operator. The Interventional Society of Australia (I.R.S.A.) and the Royal Australian and New Zealand College of Radiologists (R.A.N.Z.C.R) has draft documents indicating accreditation requirements for training in interventional radiology.

In brief the following requirements must be met:

  1. Sufficient workload to provide the necessary hands-on experience for each trainee. As a guide a caseload of 20 procedures per week per trainee is considered a minimum.
  2. Access to the other imaging modalities essential to proper performance of interventional radiology, namely CT, Ultrasound and M.R.I. The supervisor must be able to demonstrate competence in these modalities or be accredited by the R.A.N.Z.C.R
  3. In-room supervision by an individual accredited for this purpose by IRSA /RANZCR.
  4. Proof of an existing and active Quality Assurance or EQUiP program
  5. Written record of the fluoroscopy time for each procedure.
  6. Adherence to the established principles preventing self-referral for radiology procedures.
  7. Consistent billing and facility fees for all groups using equipment owned by third parties.

It has been determined by I.R.S.A. that there are two tiers of interventional radiology.

TIER A

Basic diagnostic angiography and interventional techniques - angiography, nephrostomy, abscess drainage and biopsy. This is in keeping with the training requirements of the R.A.N.Z.C.R. and any individual with R.A.N.Z.C.R. or equivalent qualifications may perform these procedures.

TIER B

  1. All neuro-interventional procedures intracranial and extracranial
  2. All vascular interventional procedures other than basic diagnostic angiography, i.e. stents, angioplasty, thrombolysis, thrombectomy, atherectomy, embolisation, retrieval of foreign bodies and laser and mechanical angioplasty
  3. Venous and arterio-venous graft interventions other than basic diagnostic venography or fistulography, i.e. thrombolysis, angioplasty, stents, atherectomy, pulmonary embolectomy/thrombolysis and caval filter insertion
  4. Biliary intervention including T.I.P.S.
  5. Thoracic intervention, i.e. embolisation of AVMs, bronchial stents, occlusion of broncho-pleural fistulae and bronchial artery embolisation Gastro-intestinal intervention, i.e. oesophageal and duodenal stents, percutaneous gastrostomy, gastrointestinal vascular procedures other than diagnostic angiography, i.e. embolisation, chemo-embolisation and transplant intervention.
  6. Urological intervention, i.e. renal artery embolisation, angioplasty or stenting, percutaneous nephrolithotomy
  7. Gynaecological - fallopian tube recanalisation, embolisation of fibroids, temporary aortic occlusion
  8. Orthopaedic - percutaneous vertebroplasty, percutaneous discectomy

In view of the small number of formal training sites so far established, accreditation for these procedures should be based on proof of a certain number of procedures performed as follows:

Minimum Training

The American Heart Association and S.C.V.I,R. have similar requirements for the performance of percutaneous angioplasty. Based on these figures and Australian experience, the following minimum training is proposed:

(i)            Performance of 300 peripheral angiograms under accredited supervision

(ii)           Performance of 50 peripheral/renal angioplasties with 25 as primary operator, with at least 10 using an antegrade femoral approach

(iii)          Performance of 30 vascular stents (15 as primary operator)

(iv)          Performance of 20 cases of peripheral vascular thrombolysis (10 as primary operator)

(v)           Performance of 10 cases of peripheral catheter guided thrombus aspiration (5 as primary operator)

(vi)          Ultrasound guided vessel puncture (20 cases as primary operator)

(vii)         Completion of an approved course in radiation biology and protection equivalent to that provided to F.R.A.N.Z.C.R. candidates

These procedures should have been performed in an I.R.S.A./ R.A.N.Z.C.R accredited site open to peer review and audit with indications, primary success and complications documented. Combined procedures are to be counted as one procedure with the exception of ultrasound guided punctures (Angiogram + angioplasty + stent + aspiration + thrombolysis = one procedure)

Proof of Quality

I.R.S.A. in conjunction with the R.A.N.Z.C.R. has produced minimum standards of practice for interventional radiology (Appendix 1). These include threshold for complication rates and expectations of success of the procedures performed. The indicators are based on an "intention to treat".

Appropriate clinical indicators

95%

Failure to obtain percutaneous access (required open procedure)

<1%

Success of diagnostic accuracy

95%

Success in crossing stenosis

95%

Success in crossing occlusion <6cm

85%

Success in renal stent placement

80%

Puncture site haematoma (requiring transfusion, surgery or delayed   discharge)

<3%

Contrast extravasation

<1%

Distal embolisation

<0.5%

Dissection / occlusion of vessels

<2%

All neurologic deficits

<4%

Permanent neurologic deficit

<1%

Radiation dose to patient and staff "ALARA"

100%

On Call and cover for annual leave

Credentialing must allow for continuity of service to cover leave and provide a 24-hour on-call service. Any additional accredited interventionist would need to take a full share of the after-hours procedures including all angiography procedures.

Equipment

Equipment standards are outlined in I.R.S.A. Standards documented on page 10. Over 75% of the procedures required for training must be performed in a dedicated angiography suite. Mobile image intensifiers are not considered in the interests of the patient or the operator.