Myocardial Perfusion Imaging (RMPI)
Testing Supplement (Add On) (e.g., SPECT, gated SPECT, planar)

An additional testing area (or areas) may be added to a facility’s current accreditation at any time during the three-year accreditation cycle. Accreditation is granted only for the specific testing areas for which a facility has applied and submitted an application. Though facilities may be performing other testing in the facility, those areas are not covered under the accreditation until an application for the specific testing type is submitted and granted accreditation.

Please answer all questions, required attachments will be indicated by the  symbol. Case studies requirements are listed on the last page. (If new staff is being added, please also submit the required staff forms.)

Name of institution (as listed in the Accreditation Agreement):
(This institution name will be tracked in the IAC database and will receive all IAC correspondence)

Application #:

Department:

Street address 1:

Street address 2:

City: State: Zip code:

Location of RMPI facility:

IAC Nuclear/PET MPI Testing Supplement – Add On1

Reviewed 3/2017

Hospital

Private office

Free-standing imaging center

Independent facility

Other (please specify):

IAC Nuclear/PET MPI Testing Supplement – Add On1

Reviewed 3/2017

1) Please indicate below which exercise and pharmacologic stress procedures are performed in the lab(s):

IAC Nuclear/PET MPI Testing Supplement – Add On1

Reviewed 3/2017

Exercise Stress (treadmill)

Dipyridamole

Adenosine

Regadenoson

Dobutamine

IAC Nuclear/PET MPI Testing Supplement – Add On1

Reviewed 3/2017

2) Indicate the annual volume this site performs in the following nuclear cardiology testing area:
Myocardial perfusion imaging (MPI) (SPECT, gated SPECT, planar):

PROTOCOLS

Please submit copy of the facility-specific Myocardial Perfusion Imaging protocol(s) that includes: indications, patient prep, radiopharmaceutical, camera set up, patient position, acquisition parameters, processing instructions and display/labeling information. (Applicable Standard: 2.4B)

Please submit a copy of the facility-specific Exercise Stress protocol(s) that includes: graded protocol(s), assessment of symptoms, injection criteria and endpoints, reasons for early termination, post stress monitoring and common adverse effects of exercise. (Applicable Standard: 2.4B)

Please submit a copy of the facility-specific Dipyridamole Stress protocol(s) that includes: infusion chart(s), assessment of symptoms, injection criteria and endpoints, reasons for early termination, post stress monitoring and common adverse effects. (Applicable Standard: 2.4B)

Please submit a copy of the facility-specific Adenosine Stress protocol(s) that includes: infusion chart(s), assessment of symptoms, injection criteria and endpoints, reasons for early termination, post stress monitoring and common adverse effects. (Applicable Standard: 2.4B)

Please submit a copy of the facility-specific Regadenoson Stress protocol(s) that includes: infusion chart(s), assessment of symptoms, injection criteria and endpoints, reasons for early termination, post stress monitoring and common adverse effects. (Applicable Standard: 2.4B)

Please submit a copy of the facility-specific Dobutamine Stress protocol(s) that includes: infusion chart(s), assessment of symptoms, injection criteria and endpoints, reasons for early termination, post stress monitoring and common adverse effects. (Applicable Standard: 2.4B)

Please submit a copy of the facility-specific Equilibrium Radionuclide Angiography protocol(s) that includes: indications, patient prep, radiopharmaceutical, camera set up, patient position, acquisition parameters, processing instructions and display/labeling information. (Applicable Standard: 2.4B):

EQUIPMENT PROTOCOLS

Please submit a copy of the facility-specific Intrinsic or Extrinsic Uniformity (flood) protocol(s): Images/documentation (hard copy or electronic) of the most recent uniformity test for all cameras must submitted with the case study materials. (Applicable Standard: 1.3.1.2B)
(Only submit if new equipment is being added.)

Please submit a copy of the facility-specific Spatial Resolution/Linearity (bar phantom) protocol(s): Images/documentation (hard copy or electronic) of the most recent resolution test for all cameras must submitted with the case study materials. (Applicable Standard: 1.3.1.3B)
(Only submit if new equipment is being added.)

Please submit a copy of the facility-specific Center of Rotation (COR) protocol(s): Images/documentation (hard copy or electronic) of the most recent resolution test for all cameras must submitted with the case study materials. (Applicable Standard: 1.3.1.4B)
(Only submit if new equipment is being added.)

Please submit a copy of the Preventative Maintenance documentation (must be within six months of submission) for all cameras: (Applicable Standard: 1.3.1.6B)
(Only submit if new equipment is being added.)

CASE STUDIES:

MYOCARDIAL PERFUSION IMAGING (RMPI) CASES:

Facilities are required to submit four complete RMPI studies performed within one year prior to the submission date; the Medical Director must have interpreted one of the case studies and only one of the studies may be normal. At least one of the studies must be an exercise stress study and atleast one must be a pharmacologic stress study. The cases must have been interpreted by as many different physicians as possible.

WHAT TO SUBMIT

As stated previously, facilities are instructed to submit all images utilized in the interpretation of a study. Therefore, for RMPI case studies, facilities should include:

  • Final report
  • EKG tracings (rest and peak stress)
  • Movies (cine) of rest and stress rotating images (to check for patient motion and overall quality) (if available)
  • Movie (cine) of gated SPECT slices (to view wall motion)
  • Reconstructed stress-rest slices (gray scale and color)
  • Calculated LVEF and time volume curve
  • Gated SPECT slices in end diastole and end systole
  • Quantitative data, polar maps, etc

For more information on RMPI case studies, visit intersocietal.org/nuclear/seeking/case_studies_NC.htm.

IAC Nuclear/PET MPI Testing Supplement – Add On1

Reviewed 3/2017