This research is the first of its kind to study the variables, organizational facets, employment terms, and labor (quality and quantity), as they exist for a sample of hospitals offering IR services. It follows the research continuum of describing, relating, and then determining cause and provides a high-quality descriptive framework upon which relational or causal studies can be based. There are a few recommendations for future research which will build upon the results of this study.
Employment Terms
Results from the analysis of this variable indicated that radiology nurses may care for more than one patient at a time which is inconsistent with current position statements issued by societies like the ACR and ARIN. Therefore, further research must be conducted to better understand the workflow and patient care models in IR. The study of nurse-to-patient ratios in procedures is broadly applicable to other areas where nurses are responsible for sedation
management. Examples include interventional cardiology, endoscopy, dentistry, the emergency room, or even some outpatient surgical centers where sedation management is the responsibility of the nurse. Nurses are required to have no other responsibilities aside from monitoring and medications if they are administering sedation (ARIN, 2018). There is no known literature that studies nurse-to-patient ratios in IR and therefore this is a significant opportunity for future study (ARIN, 2018).
Organizational Facets
The study of this variable identified variation in the use of anesthesia providers,
privileges in sedation medication administration, patient flow, and the role and responsibilities of providers in IR. The most poignant points were related to the utilization of CRNAs and the administration of propofol. Multiple studies have demonstrated the value of CRNAs based on improved patient outcomes and cost effectiveness (Dulisse & Cromwell, 2010; Hogan et al., 2010; Liao, Quraishi, & Jordan, 2015; Jack Needleman & Minnick, 2009; Pine et al., 2003).
Understanding the role and use of CRNAs in radiology is an important area for further study given the value of this provider.
While nursing practice with propofol was consistent by hospital type, a few institutions reported RNs having privileges to administer propofol sedation. The administration of propofol
by nursing is a highly controversial action marred by inconsistencies between state guidelines and various issued regulations and position statements (Bosslet et al., 2010; Dumonceau et al., 2010; Lin & Weigel, 2018; Sato et al.; Weaver, 2006). Further research on propofol is warranted as more medical groups lobby for its use by nursing during procedures outside of the operating room. This is especially important given the variability in the use of capnography described by this survey.
Characteristics of Labor
The analysis of the results of labor quality highlighted the overall inconsistencies in competencies, specific training requirements, and education. The need for further research in this area is supported by studies specific to radiology that indicate there is an effect of labor quality on patient outcomes (Bluemke & Breiter, 2000; Couloures et al., 2011; Fatima et al., 2008). However, there are significant limits to these studies and more research is needed to understand any association between radiology labor quality and outcomes. As this is a highly researched area that has shown correlations between previous experience, provider type, levels of nursing experience, nursing education, certification, and patient outcomes, there is strong support to continue this research as it applies to IR (L. H. Aiken et al., 2011; Kendall-Gallagher et al., 2011).
A study of labor quantity demonstrates the scarcity of evidence describing nurse staffing in IR. The position statements from the ACR, the ARIN, and SIR provide staffing
recommendations, but there are no studies specific to radiology reviewing the relation of labor quantity to patient outcomes. Nurse staffing has long been associated with lower rates of poor patient outcomes like urinary tract infections, upper gastrointestinal bleeding, failure to rescue, shock and cardiac arrest (L. H. Aiken et al., 2002; A. F. Minnick & Mion, 2009; J. Needleman et
al., 2002; J. Needleman et al., 2011). Further study of nurse to patient ratios, total numbers of nurses, and other aspects of staffing are required given the overwhelming evidence in the literature supporting the importance of these variables.
Radiologic Technologists
It is argued by this author that there is a clear need to complete studies relating aspects of nursing to patient outcomes in IR. The value of nursing has been demonstrated in many studies in the health services literature. While not all of these studies are specifically applicable to IR given the differences from the general hospital structure to the specialized radiologic
environment, it is hypothesized that certain aspects of variables like staffing, nurse experience, and certification will translate to positive patient outcomes in radiology. It is also noted by the author that while the need exists to continue these studies for nursing, there is an even greater need to complete studies describing these health services variables as they exist for radiologic technologists.
While nursing may be the largest workforce in the overall hospital structure, radiologic technologists are the largest workforce within radiology. Technologists are specialized providers that have an associate’s or bachelor’s degree in radiography. Depending on state requirements, they may have specific licensure or certification by the American Registry of Radiologic
Technologist (ARRT), a national organization supporting education, certification, and examination requirements (Technologists, 2018a). Technologists additionally may have specialized training in radiologic modalities that include but are not limited to magnetic resonance imaging (MRI), computed tomography (CT), nuclear medicine, and IR, as well as advanced certification in cardiac-interventional (CI) and/or vascular interventional (VI) radiography procedures ("ACR-SIR-SNIS-SPR Practice Parameter for Interventional Clinical
Practice and Management," 2014). They are experts in the care of the radiologic environment including the operation and care of imaging equipment, data management, and the quality and storage of the vital images utilized throughout the hospital by all services lines ("ACR-SIR- SNIS-SPR Practice Parameter for Interventional Clinical Practice and Management," 2014).
Given their described role as integral, irreplaceable members of the IR team, there is a significant gap in the literature studying their value.
The ARRT has a number of reports of ‘practice analyses’ that seek to describe the current responsibilities of the technologist in their specialized areas (Technologists, 2018b). These reports provide significant information as to the roles and responsibilities of these providers and begins to define the value of their care. Many studies have examined the role of
multidisciplinary team composition and its ability to decrease negative patient outcomes (Bosch et al., 2009; Epstein, 2014; He, Ni, Chen, Jiang, & Zheng, 2014). The Minnick & Roberts Outcomes Production Framework indicates that patient outcomes are a result of multiple influential factors that are not limited to nursing alone. The RT staffing in procedure rooms is typically one-to-one or even two-to-one as it relates to nursing in IR procedures. Therefore, the study of patient outcomes in IR, would not be complete without a study of technologists.