QAPI 116 - Infection Preventionist’s Role in Finding a Solution for Maintaining a Sterile Field During an yttrium-90 Radioembolization Procedure in Interventional Radiology

Background: An Infection Preventionist (IP) specializing in procedural settings observes procedures to identify risks associated with preparation, intra-procedure sterility, and room turnover during an Yttrium-90 (Y-90) radioembolization procedure being performed in Interventional Radiology (IR). A comprehensive protocol is needed to effectively maintain a sterile field while creating space for clean supplies. This protocol also addresses sterile attire education as well as intra-and post-procedure radioactive waste scanning with rate meters.

Methods: A multi-disciplinary team involving the IP, Clinical Specialist, Peri-operative Educator, Radiation Safety Officer, and IR management collaborated to produce the final protocol. Procedural guidelines for sterility maintenance, radioactive waste management, and available research studies were reviewed. Instruction for Use (IFU) documents were reviewed for all involved equipment. After no strong evidence regarding a solution was found, a combination approach was selected by improving existing practices with individual recommendations from the guidelines.

Results: The best practice approach indicated that cooperation between the physicist and the IR technologist was essential to prepare and maintain the clean and sterile spaces on the back table. Education was performed to ensure all members could properly don sterile attire. A step-by-step process was implemented for the intra- and post- procedure radioactive waste scanning to mitigate the risk of contaminating the sterile field. Proper disinfectants were added to the supply area to comply with the IFUs for the radioactive waste containers. This protocol will be given to all oncoming physicists performing this procedure.

Conclusions: Having an IP specializing in the procedural setting is critical for identifying risks. Multi-disciplinary collaboration provides the needed expertise to create and implement comprehensive plans when there are no required or strong recommendations available.