Fluoroscopic Guided Lumbar Puncture PQI Module: Pre & Post Procedure Considerations — Module B

Template Contributors: Ryan B. Peterson, MD; Kimberly Applegate, MD, MS; Ivan Dequesada, MD; Amanda Corey, MD

This template is designed to assist you in meeting Part IV of the maintenance of certification (MOC) requirements. Persons who are participating in the MOC program must select a practice quality improvement project that is relevant to their practice and that produces measurable results suitable for repeated measurements, and is able to effect quality improvement.

This template focuses patient safety, specifically minimizing complications from fluoroscopic guided lumbar punctures.  Your sample population may include inpatients and/or outpatients.

This template will take you step-by-step so you can develop your own PQI project.


  1. Review the Practice Audit Instructions and complete the Practice Audit Survey by conducting an audit of 15 charts. You may use the Example Survey to organize your review of charts.
  2. Compare your current practice to national parameters by reading the provided Practice Audit Discussion Points and National Parameters/Consensus documents
  3. Complete the appropriate education interventions (for radiologists, referring physicians and technologists)
    1. Education Intervention: For the Radiologist
    2. Education Intervention: For the Technologist
  4. Create and implement an action plan (Action Plan Template), including selecting one or more specific clinical intervention(s). 
    Example interventions include:
    1. Standardize specific medication discontinuation before lumbar puncture
    2. Create order form/process for clinicians to include pertinent history
    3. Standardize discharge instructions
    4. Mail, email or provide online link to instructional handout to patients listing risks, benefits and important information prior to arrival to procedure
    5. Providing pre-procedure information on hospital or practice website
    6. Design new guidelines concerning performing fluoroscopic guided lumbar puncture in anticoagulated or pregnant patients
    7. Develop and give educational lectures to referring clinicians on proper indications for fluoroscopic guided lumbar punctures
    8. Design post procedural instruction handout for patients
  5. Conduct a six month post-intervention follow-up chart review of 15 new patient exams.  
  6. Repeat steps #5 and #6 if clinical intervention resulted in no change or a change that did not meet the goals you set as part of the action plan
  7. Complete the Post Test
  8. Check answers with Post Test Answer Sheet
  9. Record your PQI project in myABR and keep a copy of your action plan, chart review results and conclusions reached in the event of an MOC audit

The ABR designates performance improvement activities in this project as meeting the standard for a PQI project as defined in Part IV of the MOC requirements as it includes an assessment of current practice, the implementation of an intervention, a re-evaluation and documentation of the impact of the change. This template allows the user to meet these criteria.

This is a template that can be modified as necessary to fit your practice.

Designation Statement
This material was fully qualified as a PQI template by the American Board of Radiology (ABR) on 12/16/14.

Target Audience
Radiologists and other professionals performing fluoroscopic guided lumbar punctures.

Goals and Objectives
The goal of this template is to:

  1. Reduce patient complications during or following fluoroscopic guided lumbar puncture
  2. Provide radiologists and other health professionals with a comprehensive guide in the development of PQI project that will fulfill MOC requirements.

Nothing to disclose

PQI Template Checklist

☐ Review practice audit instruction
☐ Perform practice audit survey
☐ Review “Practice Audit Discussion Points”
☐ Review “National Parameters and Consensuses”
☐ Review “Education Interventions for Radiologists & Technologists”
☐ Create and implement an “Action Plan”
☐ Perform 6-month post intervention chart review/practice audit survey
☐ Complete “Post Test” and check answers
☐ Record PQI project in myABR