PART I: DI Resident, Fellow and Staff Radiologist Orientation Manual
PART I
1.0
INTRODUCTION ...............................................................................................................................1
1.1
1.2
1.3
1.4
2.0
MODALITIES ...................................................................................................................................4
2.1
2.2
2.3
2.4
2.5
2.6
2.7
2.8
2.9
2.10
3.0
Radiologists .......................................................................................................................... 12
Contact Names and Numbers .............................................................................................. 12
Organizational Chart ............................................................................................................ 13
“HOW TO …” .............................................................................................................................. 14
4.1
4.2
4.3
4.4
4.5
4.6
4.7
4.8
5.0
Computed Tomography (CT) ................................................................................................. 5
Magnetic Resonance Imaging (MRI) ...................................................................................... 6
Magnetoencephalography (MEG) .......................................................................................... 7
General X-Ray (RA) ............................................................................................................... 7
Fluoroscopy (GI/GU) .............................................................................................................. 7
Ultrasound (U/S) ..................................................................................................................... 8
Nuclear Medicine .................................................................................................................... 9
Image Guided Therapy (IGT) ................................................................................................. 9
Nursing ................................................................................................................................. 10
Film Library ........................................................................................................................... 11
DEPARTMENT CONTACTS ......................................................................................................... 12
3.1
3.2
3.3
4.0
Introduction ............................................................................................................................. 1
DI Mission ............................................................................................................................... 1
DI Overall Goals and Objectives ............................................................................................ 2
Relationship with The Department Of Medical Imaging, University of Toronto ..................... 3
Licensing, Credentialling, Staff & University Appointments (for Fellows & Staff only) ......... 14
Hospital Bylaws .................................................................................................................... 14
Logistics................................................................................................................................ 16
4.3.1 Identification Badges ............................................................................................ 16
4.3.2 Linen Service ....................................................................................................... 16
4.3.3 Radiation Badges ................................................................................................. 16
4.3.4 Keys for Offices .................................................................................................... 16
4.3.5 Telephone Numbers ............................................................................................ 16
4.3.6 Dictaphone and Pager ......................................................................................... 16
4.3.7 Vacation/Holidays ................................................................................................ 16
After Hours Guide ................................................................................................................. 17
Radiology Information System and PACs ............................................................................ 19
4.5.1 Cerner Radiology Information System (CRIS) ..................................................... 19
4.5.2 Picture Archival & Communication System (PACS) ............................................ 19
Patient Care Policies ............................................................................................................ 21
Sedation/General Anaesthetic ............................................................................................. 23
4.7.1 NPO Guidelines ................................................................................................... 23
4.7.2 Sedation Training ................................................................................................. 23
Dictating/Reporting ............................................................................................................... 23
4.8.1 Preliminary Verbal Reports .................................................................................. 24
4.8.2 Dictating ............................................................................................................... 24
4.8.3 Radiology Reporting ............................................................................................ 24
4.8.4 Sign-Off ................................................................................................................ 24
4.8.5 DI Un-Transcribed Process .................................................................................. 24
QUALITY ASSESSMENT AND IMPROVEMENT .......................................................................... 27
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PART I: DI Resident, Fellow and Staff Radiologist Orientation Manual
DEPARTMENT OF DIAGNOSTIC IMAGING Resident, Fellow and Staff
RADIOLOGIST ORIENTATION HANDBOOK
1.0
Introduction
1.1
Introduction
Welcome to the Department of Diagnostic Imaging of The Hospital for Sick Children,
Toronto. HSC, or Sick Kids as it is often called, is a 400 bed internationally recognized
tertiary care institution located in the heart of downtown Toronto, Ontario. The Hospital
for Sick Children provides primary pediatric care for the children of Toronto, as well as
specialty care for children from other areas of the province of Ontario, the remainder of
Canada, and from around the world. Further information about The Hospital for Sick
Children and many of its programs may be obtained at http://www.sickkids.ca.
The Department of Diagnostic Imaging at HSC is one of the largest and best-equipped
pediatric radiology departments in the world. Approximately 129,000 examinations were
performed in the Department in the 2000/01 fiscal year, including 55,000 plain
radiographs, 4,000 fluoroscopic studies in the GI/GU suites, 13,000 CT examinations,
29,000 ultrasound studies, 8,000 interventional procedures, 12,000 MRI studies, 3,000
cardiac examinations, and 5,000 nuclear medicine studies. Of these examinations, 52%
were inpatient and 48% were outpatient studies. The Department has experienced a
29% increase in imaging volume in the last five years, with future such growth projected
at 5% per year.
There are currently 19.0 full-time equivalent (FTE) pediatric radiologists and three
physicists. As well, we have a pediatrician associated with the Interventional Radiology
section. In addition, there are 22.1 FTE nurses, and 57.6 FTE technologists. There are
approximately 14 fellows and 4-7 residents within the Department at any time.
The Department is an active participant in the University of Toronto radiology residency
program, and also provides pediatric radiology training for residents from Queen’s and
McMaster Universities. Furthermore, the Department supports one of the largest
pediatric radiology fellowship programs in the world, attracting clinical and research
fellows from North America, Europe, Asia, South America, Australia and Africa.
Likewise, the staff physicians are an international group, drawn to HSC from Canada,
Barbados, South Africa, Chile, the United States, South Korea and Hong Kong.
The Fellowship program in General Pediatric Radiology is accreditated (April 2007) by
the Royal College of Physicians and Surgeons of Canada, and is the first in Canada to
receive this accreditation.
1.2
DI Mission
The staff of Diagnostic Imaging at the Hospital for Sick Children is dedicated to
improving and enhancing patient care and the health of children. Our mission is
to embrace new technologies and utilize state-of-the-art equipment efficiently and
effectively, to provide an environment that supports and promotes clinical,
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PART I: DI Resident, Fellow and Staff Radiologist Orientation Manual
academic, and research excellence, and build clinical research expertise focused
on the strengths of the adjacent clinical and research community.
1.2
DI Overall Goals and Objectives
The training program in General Pediatric Radiology at the Hospital for Sick
Children is designed to provide the trainee with the world’s foremost experience
in pediatric imaging. The mission of the Department of Diagnostic Imaging at the
Hospital for Sick Children is to improve and enhance the health and well-being of
children, and our trainees play a vital role in this endeavor. Trainees will
participate in the clinical, research, and teaching activities of the Department of
Diagnostic Imaging.
The trainee in General Pediatric Radiology will acquire advanced skills in
performing and interpreting all types of imaging procedures in children, including
plain radiographs, fluoroscopy, ultrasonography, CT, and MRI. Trainees will
work alongside recognized world experts in all of these areas, and will be
assigned graduated levels of responsibility commensurate with their progress.
The breadth and volume of clinical material at the Hospital for Sick Children
affords the trainee an experience second to none.
Trainees are required to participate in research activities, as they must submit at
least one publication-ready project prior to graduating from the program.
Opportunities for research in basic and clinical science abound in this
department; our trainees regularly win top awards from international pediatric
radiology societies and are often published in the pediatric imaging literature prior
to graduation.
Trainees will also participate actively in the education of residents from radiology
and other clinical programs within the hospital. The role of the trainee as
educator is stressed, as this activity helps to prepare one for his/her future role
as a leader in pediatric imaging and as an advocate for the health of children.
Our program is now fully accredited by the Royal College of Physicians and
Surgeons of Canada, and our educational program should allow qualified
trainees more than sufficient preparation for the upcoming subspecialty
examination.
The structure of our training scheme, as well as the trainee’s evaluations, is in
compliance with the CanMEDS format as mandated by the Royal College of
Physicians and Surgeons of Canada. The individual CanMEDS roles of medical
expert, scholar, professional, communicator, collaborator, manager, and health
advocate are stressed. Specific training in these roles is provided within the
department or through the University of Toronto.
Finally, it is our goal to produce tomorrow’s leaders in pediatric imaging in
Canada and abroad. The structure of the training program in pediatric radiology
at the Hospital for Sick Children is designed to develop the strong clinical,
teaching, and research skills necessary to produce such leaders.
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PART I: DI Resident, Fellow and Staff Radiologist Orientation Manual
1.3
Relationship with The Department Of Medical Imaging, University of
Toronto
Although The Hospital for Sick Children is a separately funded institution, it is
closely affiliated with the University of Toronto. Staff radiologists are appointed
to the academic faculty of the Department of Medical Imaging, University of
Toronto, by its chairman, Dr. Walter Kucharczyk, in conjunction with the
Radiologist-in-Chief of HSC, Dr. Paul Babyn.
There are approximately 110 faculty members in the University of Toronto
Department of Medical Imaging, spread amongst eight institutions, including
approximately 19 radiologists based at HSC. The member institutions in the
University of Toronto system include: Mount Sinai Hospital, St. Michael’s
Hospital, Sunnybrook and Women’s College Health Sciences Centre, The
Hospital for Sick Children, and The University Health Network, which consists of
Toronto General, Toronto Western, and Princess Margaret hospitals. Ample
opportunities exist for interhospital educational and professional interactions.
Further information about the Department of Medical Imaging at the University of
Toronto may be obtained at http://www.utoronto.ca/imaging.
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PART I: DI Resident, Fellow and Staff Radiologist Orientation Manual
2.0
Modalities
Within the sections of the Department, a full range of imaging services is offered.
Sections include:
Body Imaging ...................... Fluoroscopy (GI/GU)
CT
 Body Imaging
MRI
 Body imaging
 Cardiac
Ultrasound
Plain radiography
 Inpatients
 Cardiac
 Outpatients/clinics
 Emergency Room
 NICU/PICU
Angiocardiography
Neuroradiology ................... CT
MRI
Neuroangiography
Myelography
Magnetoencephalography (MEG)
Nuclear Medicine ................ Nuclear studies
Bone densitometry
Interventional Radiology, (IGT) Image Guided Therapy
The following section provides for a brief description of each modality, the equipment in
each modality and their hours of operation. Some information regarding Contrast
administration in CT is also included.
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PART I: DI Resident, Fellow and Staff Radiologist Orientation Manual
2.1
Computed Tomography (CT)
There is currently one CT Scanner available 8 slice GE LightSpeed Ultra. We are
undergoing construction at this time and hope to be completed by January 2007.
CT Technologist hours: Weekdays in house 7:30 - 24:00 pager number posted
Weekdays midnight - 8:00 on call
Weekends in house 10:00 - 18:00 all other hours on call
Nurse hours for CT: Weekdays in house 7:00 - 19:00 all other hours on call
Weekends on call only
Pager numbers are posted on the white board in CT and on the
board in atrium imaging.
Before paging the following information must be available:
- Name of patient
- Age of patient
- Diagnosis/reason for request
- IV access*
- Likeliness for sedation (if sedation required last time patient ate/drank)
 *If contrast or sedation is required a PIV must be obtained by requesting
service prior to patient coming to CT Scan
 We do not inject into PICC or MIDLINES
 Central lines can be used by our fellow if they are comfortable doing so.
 If you are in doubt as to how to a scan should be preformed a protocol book
listing potential pathologies are available in the CT scan rooms
Power Injector:
 All cases needing the power injector must have a PIV with a leur lock tpiece
 We use the injector for body imaging, necks, CTA, CTV
 Radiology fellow must be in the department for all power injector cases
 PIV size – 22 gauge or bigger (a 24g can be used but is not ideal)
IV contrast doses are as follows:
Body –
1.5 ml/kg*
Head –
2.0 ml/kg*
*Maximum Dose of 100 mls.
We have strict NPO guidelines:
 NPO of solids for 8 hours
 NPO of milk and formula for 6 hours
 NPO of breast milk for 4 hours
 Clear fluids up to 2 hours prior to sedation
If a child does not meet our sedation guidelines and requires a G/A it is the MD
from the requesting service that is responsible for arranging this with anaesthesia
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PART I: DI Resident, Fellow and Staff Radiologist Orientation Manual
For all cases requiring sedation or G/A the radiology nurse and fellow must
be called in
Oral Contrast (omnipaque 300) for abdominal CT’s:
 Located in the warmer in CT – information sheets are beside warmer
 Emergency department has a supply of oral for their use
 When there is not a technologist in house and there is an abdominal scan
that needs oral contrast, it is your responsibility to deliver the oral
contrast and instructions to the patient’s nurse
***Though PACS makes it easy to check scans remotely - if a
patient’s scan is warranted urgently, then your presence will be
needed upon their arrival in the CT area. Some patients can be
very unstable and the technologist may need your assistance. ***
2.2
Magnetic Resonance Imaging (MRI)
The hospital has two GE 1.5 Tesla Signa Horizon MR Units. One unit has LX 9.1
software package with Spectroscopy, CSI, DTI and 3D Fiesta capabilities. The
other unit is a CVMR with 9.1 advanced cardiac software as well as 2D Fiesta
capabilities. The CVMR unit has Spectroscopy but NO CSI capabilities at this
time.
The MR schedule is divided between Neuro, General and Cardiac imaging to
ensure that patients are scheduled when an appropriate radiologist is available
for monitoring.
All scans are protocoled by a staff radiologist, who determines if an injection of
gadolinium is necessary. The standard dose of gadolinium is 0.2/kg.
Normal hours of operation of MR are Monday - Friday 0800 – 2300 and
Saturdays 0800 – 1600. All other times are covered by an on call Technologist
and Nurse (on-call nurse is shared with CT).




Mon & Tues a Neuro Fellow is required to arrive at 745AM to write sedation
orders.
If there is a change in the MRI schedule rotation please inform the front desk
at ext 5774. The schedule change will be written on the white board at the
front desk.
Lunch – There must be a fellow available to monitor cases or check scans
over the lunch period.
When scheduled for MRI please check before leaving for the day if there are
any scan checks etc. to ensure that a neuro case is not unmonitored on a
body evening and vice versa. If the schedule is far behind, it may be
necessary for the call person to monitor a late case.
Evenings: begin at 5PM
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PART I: DI Resident, Fellow and Staff Radiologist Orientation Manual





Covered by a Fellow or Staff Radiologist.
There is always a Staff Radiologist on call as back up for any questions or
concerns.
Tuesday evenings are booked with General Body cases.
All other evenings are booked with Neuro cases.
Please inform the front desk staff of hours worked when scheduled for the
evening. The hours are forwarded to Helene Dubois for entry on pay sheets.
SATURDAY
Saturdays are scheduled routinely to accommodate the MRI wait list as well as
urgent cases that cannot wait until the next elective booking time slot.
There is a sign up schedule at the booking desk.
Please inform the front desk staff of hours worked when scheduled for
weekends. The hours are forwarded to Helene Dubois for entry on pay sheets.
Staff required for non sedate bookings for Saturdays
 1 Receptionist
 1 Radiologist
 1 Technologist
 On-Call Technologist will be scheduled 9-12 for urgent outpatient studies.
Additional urgent cases will be arranged on an On Call basis.
 1 Nurse
On Call
For On Call information please follow P & P for Emergency On-Call Service.
2.3
Magnetoencephalography (MEG)
The MEG at Sick Kids is the first clinical MEG site in Canada. CTF Systems Inc.
(in Vancouver Canada) manufactured the system. MEG is used to measure the
magnetic fields created by the brains electrical activity. The magnetic fields are
very small and in the order of fanto-tesla. The MEG at this site collects data from
151 channels. Data is collected on this system, analyzed and then correlated
with a 3-D MRI acquisition. MEG is used primarily for epilepsy analysis,
localization and functional brain mapping.
2.4
General X-Ray (RA)
In the Atrium, there are three radiographic rooms with GE Advantx and two
radiographic rooms with Siemens generators. There are 4 mobile image
intensifiers for use in the OR and a total of 6 portable x-ray units (one is
permanently kept in pathology). As well, there is X-Ray capability in the trauma
and resuscitation rooms in the Emergency Department. A mobile 4” image
intensifer is available for use in the trauma room for simple closed reductions and
foreign body removal.
General X-Ray is open 7 days/week 24 hours/day. Urgent X-Rays are arranged
by paging the in-house technologist.
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PART I: DI Resident, Fellow and Staff Radiologist Orientation Manual
There are two additional radiographic rooms on the second floor in the DI
department, used for in-patient X-Rays, Monday – Friday during the day only
(0800-1600).
2.5
Fluoroscopy (GI/GU)
GI/GU is equipped with one digital GE fluoroscopy unit, one GE Precision 500
and one Radiography unit for conventional imaging.
All imaging from
fluoroscopic units is digital using the digital photospot camera – networked to
PACS.
The normal GI/GU hours are Monday – Friday from 0800 - 1630. After-hour
urgent requests need to be arranged with one of the Atrium Technologists by
using the pager # 416-232-4984 or 416-237-2983. The urgency of the procedure
with a timeline needs to be discussed with the Technologist. Please keep in
mind they service the whole hospital after hours so they require some time to
arrange the procedure and warm up the equipment.
2.6
Ultrasound (U/S)
The Ultrasound Department is equipped with nine ultrasound units. There are 1
ATL 5000, 4 Acuson Sequoia, and 2 GE Logic 700’s and 2 Philips IU 22’s. All
machines have colour capabilities and interface with the ultrasound PACS.
There are 6 ultrasound-scanning rooms in the main department and additional
scanning rooms in the Urology (6B) and Atrium Imaging Department. There are
also two dedicated portable units. (The Echocardiography Laboratory is
separate and is part of the Department of Cardiology.)
The normal Ultrasound hours are Monday – Friday from 0800 – 1700. A
technologist is on-call only on weekends from 0900 – 1700. Any other urgent
evening/night requests are performed by the Staff on-call, Radiology Resident,
Fellow or responsible staff physician on-call.
As of June 2006, the Ultrasound wait-list for non-urgent requests is
approximately ten working days. However, time permitting they accommodate
same day service requests. Urgent and semi urgent cases are always given
priority.
The department performs a wide variety of examinations on patients ranging
from neonates to adolescents. Examinations include: abdominal and pelvic,
obstetrical, gynecological, neurosonography, small parts (breast, thyroid, parotid,
testes), superficial lumps, transplant assessments, musculoskeletal, and
abdominal, thoracic and peripheral vascular studies.
The Ultrasound department averages 65 to 75 patients per day.
A binder with Ultrasound Scanning Protocols can be found in the ultrasound
department. The images listed in the protocols are the recommended images
that should be included with each examination.
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PART I: DI Resident, Fellow and Staff Radiologist Orientation Manual
2.7
Nuclear Medicine
Nuclear Medicine is equipped with three General Electric gamma cameras. The
Millennium MG dual head camera for SPECT and whole body scans. The two
other single head cameras, 3000XRTand 400AC, are used for dynamic and
static imaging.
The GE Lunar Prodigy Bone Densitometer is used for bone mineral density
determinations.
The normal Nuclear Medicine hours are Monday – Friday from 0800 – 1630. A
technologist is on-call until 2300 weekdays and from 0800 – 2330 on weekends
and holidays. All requests after these times must be approved by one of the
Nuclear Medicine Radiologists.
2.8
Image Guided Therapy (IGT)
The IGT suite at present consists of 4 digital angiography units, 1 CT fluoro unit
and 2 ultrasound machines. Currently the interventional section performs around
5000 procedures per year. The interventional team is made up of dedicated
technologists, nurses, 4 general interventionalists +/- a fellow and 1 neurointerventionalist.
The regular hours of operation are 08:00-18:00 Monday to Friday. After these
hours an on-call service is provided for truly emergent cases. Only medical
emergencies will be considered in order to preserve the level of weekday service.
For booking an emergency case/after-hours the process for HSC staff is as
follows. A voice message at 6054 provides the following information when an
IGT staff is not available to pick up the phone:
 During regular working hours 08:00-16:00, cases are referred to by using the
pager number 370-4327.
 Out of these hours, it is suggested that the vascular access team be paged
for vascular access queries.
 If the query concerns a GJ/G tube and it is not a medical emergency then a
message for the enterostomy nurse can be left at 7177 option 2, this is to be
answered the next working day.
 For true emergencies, page the radiology resident on-call through locating,
who then will contact the interventional staff or fellow on-call as required.
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PART I: DI Resident, Fellow and Staff Radiologist Orientation Manual
2.9
Nursing
The goal of the diagnostic imaging nurse is to provide, promote, and maintain
quality family centred care during diagnostic and therapeutic imaging procedures
through education, standards of practice, professional growth and collaboration
with other multidisciplinary health care providers.
The primary role of nurses in DI is to provide sedation for patients, or to assist
the anaesthesiologist with general anaesthesia. They also provide IV initiation,
accessing central venous catheters, and administer contrast. If nursing can
assist you in any way, please feel free to contact the Clinical Nurse Leader or
Nurse Educator for assistance.
Focus: Scope of Practice
 Knowledge of the administration and monitoring of sedation in a paediatric
patient
 Comprehensive analysis of a child’s health history and physical assessment
 Knowledge of the principles of general anaesthesia in the paediatric patient
 Radiation safety principles and practices
 Advocate of family centred care
 Administration and monitoring of contrast media
 Emergency procedures
 Research
There are nurses available in diagnostic imaging 24 hours a day, 7 days a week.
Regular hours are from 0700-2000 hours, after which there is a call nurse on
duty.
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PART I: DI Resident, Fellow and Staff Radiologist Orientation Manual
2.10
Film Library
The Film Library operational hours are advertised as Monday – Friday 0800 –
1800, however the library is currently normally staffed from 0700 – 1800. The
library is closed on weekends and holidays.
If you intend to take films from the Library to another area within the hospital, you
MUST sign out the films. Please contact one of the film librarians who will assist
in this process.
Should you require films to be retrieved for rounds or research, please give at
least 24 hours notice, preferably 2 – 3 days notice.
Accessing the Film Library After-Hours
Most images have been digitally acquired since November 1999 (some earlier)
and therefore can be viewed on PACS stations. All Ultrasound images (digitally
acquired since September 1996) are currently only available on Ultrasound MiniPACS.
If you need hard-copy films you can access the film library. Films from 2001 are
kept in the library (second floor). Films from 1996 – 2000 are in the pipe-space
in the basement, and films from 1995 and prior are in off-site storage. Films are
filed by the last two numbers first and then numerically from the other numbers
on, i.e. to find film bag #1400188, look for 88 first, and then search for 01, and
then 140.
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PART I: DI Resident, Fellow and Staff Radiologist Orientation Manual
3.0
Department Contacts
3.1
Radiologists
Below is a list of the current department physicians
RADIOLOGIST-IN-CHIEF:
Paul S. Babyn, M.D., C.M.
STAFF PHYSICIANS:
Division of Neuroradiology:
Derek Armstrong, M.B.B.S.
Susan L. Blaser, M.D.
Sylvester H. Chuang, M.D., C.M.
Suzanne Laughlin, MD
Charles Raybaud, MD, Division Chief
Manohar Shroff, M.D.
Division of Interventional Radiology:
Joao Amaral, MD
Bairbre Connolly, M.B.B.Ch., Division Chief
Michael Temple, M.D.
Philip John, M.B.Ch.B., DCH
Division of Nuclear Medicine:
Judith M. Ash, M.D.
Martin Charron, MD, Division Chief
Ruth Lim, MD
Division of Body Imaging:
Paul S. Babyn, M.D., C.M.
Alan Daneman, M.B.B.Ch., Division Chief
Andrea Doria, MD
Catherine MacDonald, M.D.
Erika Mann, MD
David Manson, M.D.
Stephen Miller, MD
Oscar Navarro, M.D.
Kamaldine Oudjhane, M.D.
Marilyn Ranson, M.D.
Karen Thomas, M.D.
Jeffrey Traubici, M.D.
Shi-Joon Yoo, M.D.
3.2
Contact Names and Numbers
A list of Department member names and contact numbers can be found in
Appendix B. Also included is a list of department member pagers.
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PART I: DI Resident, Fellow and Staff Radiologist Orientation Manual
3.3
Organizational Chart
Diagnostic Imaging Organizational Chart
Vice President of
Information and
Diagnostic Services
Radiologist-in-Chief
Director of
Research
Program
Director of
Residency
Program
 Researchers/
 Residents
Physicists
Director of
Fellowship
Program
Managing Director
Radiologists
 Fellows
Administrative
Team Leader
 Secretaries
 Transcriptionists
Nurse
Educators
Modality
Team
Leaders/
Managers
Clinical
Leader





Chief
Technologist
Technologists
Patient Info. Coordinators
Receptionists
Nurses
Unit Aides
Quality Team
Leader
Information
Systems
Team Leader


Systems
Administrator
Film Librarians
June 2003
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PART I: DI Resident, Fellow and Staff Radiologist Orientation Manual
4.0
“How to …”
4.1 – 4.2 For Fellows and Staff only
4.3 – 4.8 For Residents, Fellows and Staff Radiologist
4.1
Licensing, Credentialling, Staff & University Appointments (for Fellows
& Staff only)
In order to practice medicine in Ontario, whether as a clinical fellow or staff
physician, licensure must be granted by the College of Physicians and Surgeons
of Ontario (CPSO). The licensure process begins after the CPSO receives an
application; Immigration Canada may also be involved in this process. The
departmental Operations Assistant will assist you in obtaining the requisite
paperwork from CPSO and from the Canadian Medical Protective Association
(CMPA).
All staff and fellows must have completed an accredited residency program is
diagnostic radiology and must demonstrate:




Certification in diagnostic radiology by the Royal College of Physicians
and Surgeons of Canada, OR
Certification or eligibility of certification by the American Board of
Radiology, OR
Equivalent certification, AND
Proficiency in written and spoken English.
Credentialling is handled by the Credentialling Department at HSC. In general,
HSC requires three (3) professional letters of reference. HSC will contact your
prior place(s) of employment in order to assess your suitability for appointment.
Liability insurance is provided for staff radiologists and fellows by the hospital
through CMPA.
For staff radiologists, appointment to the medical staff of the Department of
Diagnostic Imaging at The Hospital for Sick Children is arranged through the
Radiologist-in-Chief. Academic appointment to the Faculty of Medicine,
University of Toronto, is arranged through the office of the Chairman of the
Department of Medical Imaging, in consultation with the Radiologist-in-Chief of
HSC. The level of appointment will be based upon previous academic
production and professional stature.
Department Assistance with Documentation
The department will assist staff and fellow candidates in acquiring and
processing the necessary documents required for appointment, licensure and
residency.
Fellows contact: The Administrative Services Team Leader
Staff Radiologist contact: Administrative Assistant to the Radiologist-in-Chief
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PART I: DI Resident, Fellow and Staff Radiologist Orientation Manual
4.2
Hospital Bylaws
The Medical and Dental and Scientific Staff of The Hospital for Sick Children
shall be organized as per The Hospital for Sick Children By-Laws. A copy of the
Bylaws are included in Appendix A of Staff Radiologist Orientation Manuals they
can also be found on the HSC intranet at:
http://hscweb.sickkids.on.ca/bookshelf/HSC_BYLAWS/bylaw.htm
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PART I: DI Resident, Fellow and Staff Radiologist Orientation Manual
4.3
Logistics
4.3.1 Identification Badges
Photo identification badges must be worn.
They may be obtained from the Human
Resources Department.
4.3.2 Linen Service
A size request form for uniforms may be
picked up at the Medical Appointments
Office. A deposit of $15.00 for two lab
coats is required. If/when uniforms is no
longer needed, you must return the
uniforms to Linen Services (service level,
room #S602) in order to receive deposit
back.
4.3.3 Radiation Badges
Every Resident, Fellow and Staff
Radiologist must complete a badge
application and submit it to the Chief
Technologist (room #2247). These badges
must be returned if employment/term has
ended.
4.3.4 Keys for Offices
Office assignment and keys for your office
can be obtained from the DI department.
Residents
Obtain from
Human
Resources
(525 University
Avenue)
Fellows
Obtain from
Human
Resources
(525 University
Avenue)
Staff
Obtain from
Human
Resources
(525 University
Avenue)
See Medical
Appointment
office and then
Linen Services.
See Medical
Appointment
office and then
Linen Services.
See Medical
Appointment
office and then
Linen Services.
See DI
Resident
Program
Director’s
secretary.
See DI
Administrative
Team Leader
for application.
See DI
Administrative
Team Leader
for application.
See DI
Resident
Program
Director’s
secretary.
See DI
Administrative
Team Leader
for keys and
office location.
See DI
Administrative
Team Leader
for keys and
office location.
You may have
your own
phone in your
office. See DI
Admin. Team
Leader
You may have
your own
phone in your
office. See DI
Admin. Team
Leader
See DI
Resident
Program
Director’s
secretary.
See DI
Administrative
Team Leader
for dictaphone
and pager.
See
Administrative
Assistant for
dictaphone and
pager.
See Chief
Fellow.
See Chief
Fellow.
See your
Division Head
and then the
Radiologist-inChief.
4.3.5 Telephone Numbers
The Hospital Switchboard/Locating is
7500. If your bellboy rings with 0000
displayed, please call locating directly.
4.3.6 Dictaphone and Pager
You will receive a dictaphone and pager
from the department.
4.3.7 Vacation/Holidays
Holidays must be requested in writing and
scheduled in advance.
Last Revised: January 1, 2008
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PART I: DI Resident, Fellow and Staff Radiologist Orientation Manual
4.4
After Hours Guide
There are technologists and nurses (one nurse for CT/MR and one for Interventional)
on-call for the various modalities. Up to date contact information is located at the Atrium
Imaging Desk. It is the Fellows/Radiologists responsibility to check as to whom is on call
(there is a receptionist near the board at x6090, until 21:00). In most cases staff prefer
their home number phoned first and then the pager used if necessary.
For all after-hour studies/procedures please have ready for the technologists before you
page them:
 Name of patient
 Age of patient
 Location of patient
 Type of Study
 Urgency of Procedure
 Type of contrast needed (if applicable)
 If the child requires sedation,
 when the patient last ate/drank
 Cardiac status
 Any airway problems
 Fever, Nausea & Vomiting
If a study/procedure requires sedation, the patient must meet the sedation guidelines
before sedation can be commenced (see section 8.0). Exceptions may be arranged
during emergencies and the Emergency Department Staff and/or Anaesthesia manage
these patients usually under the auspices of the Trauma Team..
If a MRI is requested, a MRI screening form must be filled out by an appropriately
informed person, prior to the patient arriving in the department. If an appropriate person
is not available or cannot be contacted, the Staff Radiologist must be contacted and the
risk(s) to the patient must be ruled out before the scan is performed.
If a patient’s scan is warranted urgently, then the Resident/Fellows must be present
upon the patient’s arrival in the area, as these patients may become rapidly unstable. In
all imaging areas within the Annex (the older hospital building – this includes CT, NM,
US, and GI/GU), there are no “CODE” buttons present.
To call a code, one must dial 25 and give information for the room number,
location, etc.
If it is decided that a case can be done the next day, the staff in the appropriate modality
must be informed and consulted for an appointment time. The urgency of the study will
determine how the schedule is rearranged to accommodate the urgent patient.
The table to follow includes a summary of hours of operation for each modality as well
as a summary of after-hour procedures.
Last Revised: January 1, 2008
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PART I: DI Resident, Fellow and Staff Radiologist Orientation Manual
Hours of Operation and After Hours Guide
Modality
CT
Normal
Working Hours
07:30 – 19:00
Monday – Friday
(A tech. is inhouse Mon. to
Fri. up to 24:00
and a tech. is inhouse weekends
& holidays from
10:00 to 18:00)
General
X-Ray
GI/GU
24 hours 7
days/week
08:00 – 16:30
Monday – Friday
08:00 – 17:00
Monday – Friday
Image Guided
Therapy (IGT)
MRI
08:00 – 20:00
Monday - Friday
Nuclear
Medicine
08:00 – 17:00
Monday – Friday
Ultrasound
08:00 – 17:00
Monday - Friday
MEG
Scan times are
0800 – 0400
Tuesday –
Thursday
Last Revised: January 1, 2008
After Hours Emergency Exam/
Procedure Process
Monday – Friday a technologist is in-house until 24:00 and carries a
pager. Weekends and holidays a technologist is in-house between
10:00 – 18:00.
Urgent CT Request Process:
 Radiology Resident is paged.
 Radiology Resident pages on-call Tech., Fellow and if sedation is
required, the on-call DI RN.
 The Fellow must review all CT Body cases before patient is
removed from CT. The DI Resident must review all CT Neuro
cases before patient is removed from CT.
 If the case is to be done first thing the next morning, please call
ext. 8262 and notify the 07:30 technologist.
(No cases prior to midnight should be put off to the next day, as there
is a technologist in-house until midnight.)
Urgent X-Rays are arranged by paging #237-2983
Contact a technologist in the Atrium X-Ray area by phoning 6090 or
paging at #237-2983
 For Vascular Access queries, page IV Team.
 For G or GJ tube concerns call the G-tube nurse at 813-7177 if nt
urgent.
 For other emergencies the Radiology Resident will be paged.
The Radiology Resident will contact the Interventional Radiology
Fellow or Staff as required.
 Resident contacts the Fellow-on-Call.
 Staff Radiologist must approve after-hours exams.
 Fellow will contact on-call Technologist and DI RN if required.
 Radiology Resident is paged.
 Radiology Resident contacts on-call NM Fellow or Staff if none
available.
 Once exam is approved Radiology Resident contacts on-call
technologist.
 A technologist is available on-call until 23:00 weekdays and from
08:00 – 23:30 on weekends and holidays. For any request after
23:30, Drs. Gilday or Ash must review request.
 A technologist is on-call only on the weekends from 09:00 to
17:00 hours.
 Any other urgent evening and night requests are preformed by
the Radiology Resident, Fellow, or Staff on-call.
N/A
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PART I: DI Resident, Fellow and Staff Radiologist Orientation Manual
4.5
Radiology Information System and PACs
4.5.1
Cerner Radiology Information System (CRIS)
The Department of Diagnostic Imaging uses application software from Cerner
Corporation for the basis of our radiology information system (RIS). The system
is known as CRIS (Cerner Radiology Information System). Cerner provides the
user with access to appointments, orders, and results, as well as, transcribed
and finalized radiology reports. Cerner is installed on all PC’s within the
department, as well as in the Urology and Haematology Clinic’s. GE PACS
(picture archiving and communication system) and CRIS have provided an
interface between the systems that allows Radiologists to view images on PACS
while finalizing (reviewing and electronic signing) reports in Cerner.
Training on CRIS
Training on the Cerner system occurs within the first few days of arrival in the
Department. New Residents, Fellows and Staff Radiologists find it an intuitive
system to navigate.
The DI Cerner team will arrange for KIDCOM/Toolbar by the HSC clinical training
group. KIDCOM is the Hospital-wide Information System (HIS) containing patient
information on all of our In/Out and ER patients. The KIDCOM Toolbar
application also provides access to Lab results (which are often required after
hours).
4.5.2
Picture Archival & Communication System (PACS)
The PACS (Picture Archiving and Communication System) by GE is a group of
devices such as scanners, servers, and workstations used to view and archive
medical images digitally. Our PACS application is enterprise meaning that the
images are with attached report available throughout the hospital. A user can
use one of many diagnostic workstations to review digital images by retrieving
them from a centralized digital image archive. When a digital scan is performed,
instead of creating films for each scan, the Technologist/Radiologist performing
the scan simply sends the digital images from the scanner to a digital archive for
storage.
Currently, the PACS is in full compliance with the DICOM (Digital Imaging
Communications in Medicine) protocol and hence very easily integrates with any
DICOM compliant system.
The PACS is capable of supporting various modalities. Currently the HSC PACS
supports:
Computed Radiography (CR)
Computed Tomography (CT)
Magnetic Resonance Imaging (MRI)
Radiography/Fluoroscopy (RF)
Angiography (XA) -- Of the two IGT (Interventional) fluoro units presently in
service in the department, only one unit has been integrated to work with the
Last Revised: January 1, 2008
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PART I: DI Resident, Fellow and Staff Radiologist Orientation Manual
PACS. The second unit is not part of the system since it does not have DICOM
support and images are printed on film only.
Currently, the Nuclear Medicine and Ultrasound departments have their own
mini-PACS that are self-contained. For Ultrasound, the images are not available
via the GE PACS at present, however a description of the ultrasound exam as
well as the report for the exam are accessible through the system. For Nuclear
Medicine, mini-PACS images are sent to the GE PACS and reports are available
on the GE PACS.
There are two ways to view softcopy (digital) images at HSC.
1.PathSpeed
A PathSpeed workstation consists of powerful High Resolution monitors
providing high quality digital images. Currently, HSC has 3 to 4 PathSpeed
workstations deployed in each modality. Many clinics at HSC (including ER
and the Trauma Room) also have high-resolution monitors for diagnostic
viewing and others will be implemented throughout 2001.
2. PACS Web:
PACS Web is a web-based application that provides access to images
through an Internet Browser (Internet Explorer 5 or higher). PACS Web is an
efficient and easy way to view images.
The PACS Web address is: http://pacsweb To login into the system, a valid
user ID and password is required. This user account is issued to you at the
time of PACS training. As an added convenience if a valid user has access
to the hospital system from their home, he/she can access PACS web.
PACS Training:
Training on the PACs occurs within the first few days of arrival in the Department.
If you have general inquires or, you are experiencing any problems with the
PACS, please contact the PACS Team at phone #: 235-9178. There is 24hr
urgent support.
Last Revised: January 1, 2008
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PART I: DI Resident, Fellow and Staff Radiologist Orientation Manual
4.6
Patient Care Policies
DI Patient Care policies and procedures (P&P) can be found in the DI P&P manual.
Many clinical P&P’s are under revision in the department. If you have any questions
regarding DI procedures please contact any Staff Radiologist, the DI Nurse Educator or
DI Clinical Nurse Leader.
Relevant DI Clinical Policies and Procedures in DRAFT form include:
 Contrast: Administration of Intravenous Contrast
 Contrast: Administration of Oral Contrast
 Contrast: Administration of Rectal Contrast
 Contrast: Administration of Intravenous Gadolinium
 Managing Contrast Reactions in Children
 Power Injector
 Premedication of Patients with a History of Prior Adverse Effect to Contrast Media
 Treatment of Extravasation Injuries from Omnipaque 300
4.7
Sedation/General Anaesthetic
Sedation or General Anaesthetic is required for procedure or tests that may be anxietyprovoking, painful, require cooperation, or an immobile patient. The Hospital for Sick
Children (HSC) has developed comprehensive guidelines for children requiring sedation.
Children that do not meet these guidelines, still requiring sedation, are given general
anaesthetic. The HSC "Guideline for Care of a Child Receiving Conscious or Deep
Sedation" describes the purpose and goals of sedation as well it describes the entire
sedation procedure from pre-assessment to discharge. For Fellows and Staff, Appendix
C contains a copy of the Guideline as well as Guide to Commonly used sedatives and
analgesic agents.
If a child does not meet the criteria for sedation and a General Anaesthetic is required,
the Radiologist (Resident/Fellow) On-Call must take the necessary steps to ensure that
the G/A is arranged accordingly to protocol. This process includes the following:
 Page Anaesthesia –on-Call to discuss the case, including urgency, NPO status etc.
 The ordering physician must call the OR desk to have the child put on the OR ‘AddOn’ Board ex. 6849
 The OR will inform the PACU RN ‘On-Call’ when to come in to recover the patient
 The Staff Anaesthetist must be present for the administration of anaesthesia
 The Radiologist must page the DI ‘On-Call’ RN to inform her of the time of the
procedure (Allow 45 minutes for her to arrive at the hospital)
Cases requiring sedation can only be performed with a Radiology Fellow or Staff
Radiologist present. Residents cannot order sedation.
To follow is a very brief and general list of basic criteria a patient must meet to be
considered for sedation. For more detailed information please refer to HSC Sedation
Guideline.
Last Revised: January 1, 2008
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PART I: DI Resident, Fellow and Staff Radiologist Orientation Manual
General Criteria for Sedation:






ASA classification of I or II
NPO guidelines followed (see section 8.1)
Normal cardiovascular status
Normal respiratory status
Normal airway status
Weight less than 33 kg
4.7.1
NPO Guidelines
The following is taken direction from “Guidelines for Care of a Child Receiving
Conscious or Deep Sedation”. 1 See Appendix C for complete Guideline.
An assessment and documentation of food and fluid intake must be completed
prior to any sedation because the level of sedation is unpredictable. Therefore,
children who intentionally or unintentionally become deeply sedated may lose
their protective airway reflexes and gastric contents may be regurgitated into the
airway. It is important to assess for patients who may be at risk for pulmonary
aspiration of gastric contents (e.g. history of gastroesophageal reflux,
esophageal dysfunction, hepatosplenomegaly, abdominal distension, extreme
obesity, or pregnancy).
Staff need to be aware of the sedation guidelines with respect to NPO status to
help arrange for on-call studies.
Patients must be NPO prior to sedation for:
 8 hours for solids
 6 hours for formula and milk
 4 hours for breast milk
 2 hours for clear fluids
For the emergency patient, the use of sedation must also be preceded by an
evaluation of food and fluid intake. When proper fasting can not be assured, the
increased risks of sedation must be carefully weighed against its benefits, and
the lightest sedation should be used and documented in the patient chart. If
there is any conflict between the DI HSC Sedation Policy vs. the Emergency
Department, then the Emergency Room MD who still wishes to sedate the child
must assume the management and the responsibility of the sedation, monitoring,
and recovery of the patient. DI nurses limit their practice within the HSC
Sedation Guidelines and may refuse to sedate a child who does not meet the
criteria for a safe, nurse-administered sedation.
“Guidelines for Care of a Child Receiving Conscious or Deep Sedation”. The Hospital for Sick Children.
Revised: April 1999.
1
Last Revised: January 1, 2008
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PART I: DI Resident, Fellow and Staff Radiologist Orientation Manual
4.7.2
Sedation Training
Fellows and Staff Radiologists must show proof of current BCLS to the HSC DI
Nurse Educator. PALS (Paediatric Advanced Life Support) is required to be
credentialed in IGT.
Fellows and Radiologists must participate in DI Sedation Classes. These
classes are offered regularly and are arranged through the DI Nurse Educator.
Last Revised: January 1, 2008
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PART I: DI Resident, Fellow and Staff Radiologist Orientation Manual
4.8
Dictating/Reporting
4.8.1
Preliminary Verbal Reports
Verbal preliminary reports should also be written on patient’s Exam Detail Form,
or in the patient chart. The Resident, Fellow or staff Radiologist should also
include the date, their signature and the name of the individual they spoke with.
Any discrepancies between the preliminary report and the final report should be
directly communicated to the responsible clinician. This communication should
be documented on the final report with details provided on the time of the
communication and with the person directly spoken to.
4.8.2
Dictating
The department goal is to have reports typed, signed off and ready for
distribution within 24 hours from the time of examination to end. The following is
a protocol for dictating cases in all areas of the Diagnostic Imaging Department.
Following these steps when dictating will assist in maintaining quality assurance
and efficiency. See Protocol on next page.
4.8.3
Radiology Reporting
Residents/Fellows will include a summary of report written on the exam detail
form, which are correlated daily and kept on file. The Resident/Fellow will print
their last name and the name or initials of the staff radiologist with whom they
have reviewed that case. You will be shown how to use the CERNER Radiology
information system during your first week. Dictations should be reviewed quickly
and signed-off expeditiously. Please keep your dictations concise and clear.
4.8.4
Sign-Off
The signing-off of reports should be performed on a daily basis. It is
recommended that you sign off cases first thing in the morning and at the end of
the day to ensure cases are not left pending for an unacceptable prolonged
period of time. If you reject a report, please include a note explaining your
reasons for rejecting. The transcriptionists will make the necessary changes and
re-save the report.
4.8.5
DI Un-Transcribed Process
The DI Department has a goal of 24 hour Report Turn Around Time. Daily each
modality Team Leader reviews list of un-reported studies and trouble-shoots any
problems. Radiologists are notified of un-reported studies more than 24 hours
old.
Last Revised: January 1, 2008
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PART I: DI Resident, Fellow and Staff Radiologist Orientation Manual
Preliminary reporting in US, CT, GI-GU, MRI, & NM for in-patients and
emergency patients
Exam completed
Staff Radiologist completes
Preliminary Report
Or
Fax or forward copy to the
responsible clinician
Fellow / resident completes Preliminary
Report
The original
Preliminary Report
remains in
Diagnostic Imaging
Need for immediate review
with Staff Radiologist?
Yes
Staff Radiologist
available?
No
Yes
No
Calls Staff
Radiologist on-call
Fellow / resident immediately reviews
Preliminary Report with Staff
Radiologist and fax or forwards copy
to the responsible clinician
The original
Preliminary Report
remains with
Request For
Diagnostic Imaging
Fellow / resident fax or forwards copy of
Preliminary Report to the responsible clinician
Fellow / resident reviews Preliminary Report
with Staff Radiologist
Communicate to the
responsible clinician
Yes
Discrepancy?
Document
communication details
on the Preliminary
Report
Document discrepancy & communication
details on the Final report
Last Revised: January 1, 2008
No
Regular reporting process
Final report
Page 25
PART I: DI Resident, Fellow and Staff Radiologist Orientation Manual
Dictating Protocol:
Always speak clearly and concisely and spell out any unusual words.
1. When beginning your dictation, please clearly state:
 your name,
 the first and last name of the individual you are dictating with (i.e. resident, fellow,
and/or staff Radiologist) and,
 the date of your dictation.
This information must be entered before the transcriptionists can begin typing.
2. Change tapes when changing dictations with another Radiologist.
3. Next, clearly dictate the:
 Patient’s accession number(s), (a two-letter designation consistent with modality,
followed by the year and then a 5-figure identification number, e.g. CT-02-01234, MR02-00345, etc.)
 Patient’s name, (please include the patient’s HSC # and spell the patient’s name),
 Date of the study, and
 Type of exam(s) (to ensure that the dictation and accession number are properly
matched). This is especially important in the case of multiple dictations for one patient.
 Next, follows the report
4. At the end of the dictation, clearly state that this is the end of the dictation as to avoid
mistakes with long pauses between dictations.
5. When you have finished dictating please remove the photomarker(s) from the requisition(s)
you have completed, and submit the photomarkers and tape to room 2107C (steno pool
area). We have transcription coverage daily (Monday to Sunday). Place your dictation in
the provided envelope and label it with your name, the date and area of reporting. Dictation
is done in order of its arrival. Please submit your dictation as soon as possible and do not
hold onto tapes. Please submit tapes as many times as possible throughout the day –
do not hold on to your tapes. This will help to ensure 24-hour turnaround of dictation.
6. Your reports will be typed into our radiology information system (CRIS). CRIS identifies
examinations by the exam accession number. This ensures that reports are transcribed with
the proper images.
If you encounter any problems regarding dictation or transcription, please see the DI
Administrative Services Team Leader.
Last Revised: January 1, 2008
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PART I: DI Resident, Fellow and Staff Radiologist Orientation Manual
5.0 Quality Assessment & Improvement
Both structurally and functionally, the Department of Diagnostic Imaging relentlessly
pursues innovative solutions to meet the needs of each and every patient and achieve
operational excellence in the delivery and quality of our services. We are committed to
the exceptional customer service while recognizing and respecting the diversity of the
patients and customers we serve.
The key drivers of the DI Quality and Risk Management program include Quality
Assessment and Improvement Committee, monthly DI and IGT Morbidity and Mortality
Review Rounds, Patient Care Committee, Radiation & Occupational Safety Committee,
and a dedicated Quality Management Leader.
QA&I Committee is an interdisciplinary team that provide strategic direction for quality
improvement activities within DI, and make sure we understand and fully meet the needs
of our patients, families, and other customers. The committee is also responsible for:
Review of the Incident Reports; Selection and analysis of quality indicators; Taking
action based on indicator results and/or incident reports; Planning, implementation, and
evaluation of improvement initiatives; Monitoring implementation of recommendations
made at M&M Review Rounds; Dissemination of information; and Monitoring of external
initiatives and standard upgrades.
Continually refined monthly Quality Indicators used to measure, evaluate, and improve
effectiveness of our processes are at the core of DI quality management program.
Every effort is made to enable sound decision-making by creating selective, reliable,
responsive, valid, and cost-effective measures of performance. Examples of monthly DI
Quality Indicators include: Report turnaround time, appointment wait time, number and
type of exams, number of patients by sedation type, etc.
Department of Diagnostic Imaging has developed and introduced a number of new
Quality Management Tools and Processes in order to identify, understand, and address
the systemic opportunities for improvement. These tools and processes have been
designed to prevent or minimize reoccurrence of undesirable outcomes, promote a
culture of continuous quality improvement through the teamwork, reduce waste, and
eliminate non value-added process steps.
Reporting of Incidents
The Hospital for Sick Children has implemented the new online Safety Reporting System
designed to provide real time reporting of various incidents, eliminate multiple paper
forms, and enhance opportunities for learning and sharing of information. The
knowledge generated through this process allows us to make system improvements. For
complete information please refer to the HSC Policy and Procedure “Safety Reporting”.
Morbidity and Mortality Review
The main purpose of DI and IGT Morbidity and Mortality (M&M) Review Rounds is to
determine if the care provided was appropriate and timely, to provide educational value
for all participants, identify issues and trends, develop new knowledge, and further
improve upon the care provided. A morbidity event is defined as “an untoward event or
Last Revised: January 1, 2008
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PART I: DI Resident, Fellow and Staff Radiologist Orientation Manual
complication which, under optimal conditions, is not a natural consequence of the
patient’s disease or treatment”. Please note that a morbidity event does not
automatically mean that there has been an error in the process of care delivery.
Potential M&M cases should be submitted to either the chair of DI M&M Committee or
the DI Quality Management Leader by including the patient’s initials, HSC number, and a
short summary of the issues. Staff radiologists, nurses, technologists, residents, and
fellows are asked to present the cases at the M&M reviews. Presentation is followed by
group discussion of the issues in order to identify potential opportunities for
improvement. The entire DI department is invited to attend the M&M reviews including
the guests from other clinical areas that may be involved in the cases. The M&M reviews
are structured so that they count towards an accredited group learning credit for
Maintenance of Certification with the Royal College of Physicians and Surgeons.
The following headings should be used when preparing and presenting a case:

Case Summary: Provide a brief case summary with imaging where appropriate. Do
not use staff names in case summary.

Summary of Issues: Provide a summary of issues arising from the case.

Discussion and Summary of Relevant Literature: Discussion of each issue with
review of literature when appropriate.

Recommendations for Improvement (if applicable): Potential recommendations
stemming from each issue should be developed from literature, standard practice
and consensus of meeting participants. If final recommendations cannot be
established at the M&M review, the M&M Chair will direct a working group to be
struck with a request to report back to the M&M rounds by a specified time.
Last Revised: January 1, 2008
Page 28