Use of Barium Sulfate Contrast During Videofluoroscopic Swallowing Studies

• Barium is considered a medication and must be treated as such and kept under lock and key.
• The amount and type of barium used during the study must be recorded.
• SLPs must have established competencies in the use and storage of barium.

Joint Commission Clarification of MM 4.10

MM 4.10: "All prescriptions or medication orders are reviewed for appropriateness." (Joint Commission, 2004, p. MM-13).

The following clarification was published in the June 2005 issue of Joint Commission Perspectives (Vol. 25, Issue 6):

1. Contrast media, [including barium contrast used during VFSS], are considered a medication.
2. Review of administration of barium by a pharmacist, while not required, is a recommended safety step.
3. The organization must adopt clinical practice guidelines or approved screening tools to address the safe. administration of barium. In hospitals, guidelines or screening tools must be approved by the medical staff or pharmacy.
4. Only trained, designated personnel can retrieve medications from storage.
5. The appropriateness of using barium must be reviewed by a qualified health care professional.
6. Quality control procedures must be set up to prevent retrieval errors.
7. If needed, a pharmacist should be on-call.
8. A quality control review of previous records in which administration of barium was done without prior pharmacy review should be done to identify any problems.

Ways in which facilities are handling these requirements (as reported by members):

• Barium is kept under lock and key.
• Radiology techs have the key and will unlock the cabinet to get the Ba before the procedure or at the request of the SLP; in some facilities, the SLP has a key and access to the stored barium.
• Documenting amount of barium and, in some cases, the lot number for the barium.
• Radiology techs write a note indicating that the procedure was completed and how much barium was used.
• SLPs document the ratio of barium to food or liquid presented and the exact amount given.
• All containers that have barium mixed into the food or liquid must be clearly labeled.

SLPs' reports of how Joint Commission surveyors have responded:

• "We were just surveyed last week. This issue was not even mentioned as far as I know."
• "Our inpatient hospital just recently had a Joint Commission survey. We "heard" and therefore implemented the use of barium under lock and key. We did not hear, nor were we asked about exact tracking of use or competencies in the use of barium."
• "We are reportedly required by Joint Commission to keep the barium under lock and key, but I have not heard of the other requirements you mention."
• "Jars of powdered barium sulfate that we use for our studies were moved out of the rooms where we conduct fluoroscopy to be stored in a locked closet. Now, when we want to prepare our materials for a VSE we have to find a radiology tech with a key to the closet so that we can get the barium we need."
• "We have been asked (or required) to record barium lot numbers for both inpatient and outpatient MBSs. We document them in our reports."
• One facility recently passed a Joint Commission survey by keeping barium under lock and key and having the techs indicate the amount of barium used during the procedure.

Facts About Barium Contrast

(from Barium Sulfate Safety Issues and Patient Protection Measures by Karen Brown, CCC-SLP):

• Barium sulfate is the most commonly used contrast material for the videofluoroscopic swallowing study (Tamm and Kortsik, 1999).
• When administered orally, barium sulfate produces high diagnostic yield with low risk of adverse events (Ansell, 1987).
• Barium sulfate is an insoluble salt and is almost completely nontoxic.
• Sources of complications include:
• Aspiration of large quantities of barium
• Complications reported in the literature come from the amounts of barium used for GI studies (Voloudaki, et al, 2003). The amount of barium used for the VFSS is much smaller.
• While there have been reports of complications and even death with aspiration of large amounts of barium (Gray, et al, 1989), problems associated with ingestion of barium are very rare (Tamm & Kortsik, 1999).
• Even in patients who have aspirated large quantities of barium, the long-term prognosis after treatment has been found to be "excellent due to the inert character of barium sulfate" (Tamm & Kortsik, 1999).
• Problems that may cause intestinal stasis (e.g., bowel obstruction)

References and Resources

Ansell, G. (1987). Alimentary tract. In G. Ansell & R.A. Wilkins, Complications in diagnostic imaging (2nd ed.), (pp. 218-246). Oxford: Blackwell Scientific.

Buschman, D.L., (1991). Barium sulfate bronchography: Report of a complication . Chest, 99 , 747-749.

Erickson, L.M., Shaw, D., & MacDonald, F.R. (1979). Prolonged barium retention in the lung following bronchography. Radiology, 130 (3), 635-636.

Gray, C., Sivaloganathan, S., & Simpkins, K.C. (1989). Aspiration of high-density contrast medium causing acute pulmonary inflammation - Report of two fatal cases in elderly women with disordered swallowing . Clinical Radiology, 40 , 397-400.

Joint Commission. (2004). Comprehensive Accreditation Manual for Hospitals: The Official Handbook, Oakbrook Terrace, IL: Author.)

Rasley, A., Logemann, J.A., Kahrilas, P.J., Rademaker, A.W., Pauloski, B.R., & Dodds, W.J., (1993). Prevention of barium aspiration during videofluoroscopic swallowing studies . American Journal of Reontgenology, 160 , 1005-1009.

Skucas, J. (2000). Contrast media. In R.M. Gore & M.S. Levine (Eds.), Textbook of gastrointestinal radiology (2nd ed.), (pp. 2-14). Philadelphia: W. B. Saunders.

Tamm, I., & Kortsik, C. (1999). Severe barium sulfate aspiration into the lung: Clinical presentation, prognosis and therapy . Respiration, 66 , 81-84.

Valoudaki, A., Ergazakis, N., & Gourtsoyiannis, N. (2003). Late changes in barium sulfate aspiration: HRCT features . European Radiology, 13 , 22266-2229.

Whiting, J. (2003). Aspiration of barium. (Letter to the editor). New England Journal of Medicine, 348 (25), 2582.