Radiation Dose Management: A Patient Safety Priority

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Advances in diagnostic imaging have transformed patient care, enabling timely, effective decision-making and ultimately saving lives. The benefits, however, do not come without risks. Overexposure to radiation is linked to cancer; a 2009 study published in the Archives of Internal Medicine estimates 29,000 future cancers and 14,500 future deaths may result from the 72 million computerized tomography scans performed in the United States in 2007.

Calculating the risk to patients is a complex process that often doesn't generate any clear answers. Still, radiation dose management is becoming a top patient safety and quality issue for hospitals. "It's true the magnitude of the health risk for medical diagnostic scanning is not unequivocally clear," says Keith White, M.D., medical director of imaging for Intermountain Healthcare, Salt Lake City. "We have an obligation to our patients to mitigate the risk as best we can." Intermountain launched an initiative last year to reduce patients' exposure from CT scans by 50 percent.

The development of comprehensive, radiation dose-management programs provides a systematic way for hospitals to track, report and monitor radiation dose and eliminate unnecessary exposure. These programs focus on building processes to ensure that the right test is performed on the right patient and in the right dose. "The goal is to match the image quality based on the clinical indication and the individual patient based on body size and weight, among other things," says Dushyant Sahani, M.D., director of computed tomography for Massachusetts General Hospital, Boston.

The establishment of radiation dose-management programs is not without its problems. One of the keys to success is education and training among all stakeholders. "Physicians don't necessarily, as a body, believe the risks associated with radiation dose are as written," says White. "There's a lack of understanding and knowledge in the medical community in general." It's important to build awareness of the potential risks of radiation exposure among senior leadership, physicians, including referring physicians, as well as technologists, patients and patients' families.

Another challenge is the fast pace of technological development. "Technology is moving so quickly it's hard for medical professionals to stay current," says Marilyn Goske, M.D., a staff radiologist for Cincinnati Children's Hospital. In many instances, the technology is not being used to its fullest extent to help reduce radiation exposure. Forming strong vendor relationships and participation in accreditation programs for technologists are two ways to overcome that challenge.

Radiation dose-management programs should involve a multidisciplinary team, including radiologists, radiologic technologists and radiation physicists. "Organizations need systems in place that allow the constant observation of adherence to protocols and procedures, says Elliot Fishman, M.D., director of diagnostic imaging and body CT, for Johns Hopkins Medicine, Baltimore. It's important to monitor changing recommendations from the scientific community as well, Fishman adds. Protocols and procedures should be evaluated at least once or twice a year.

Patient and family involvement is also critical, especially among pediatric patients. "Children are more vulnerable to radiation exposure," Goske says. It's important that individuals and their families are aware of the test and the radiation dose the patients are receiving. "You have to have that discussion in order to achieve quality and safety," she says.

Three keys to eliminate avoidable radiation

The appropriate use of radiation is an important patient safety and quality issue. Radiation dose-management programs should focus on determining the right test at the right dose in a timely fashion. At a minimum, radiation dose-management programs should focus on three goals: Ensure that the test is clinically indicated; avoid duplicate tests; and make sure alternative tests, such as an ultrasound or magnetic resonance imaging, are not viable options.

These key steps will assist organizations in the development of comprehensive radiation dose-management programs.

Promote the safe use of imaging technology

•Radiation dose management should be part of the organization's patient safety program.

•Seek accreditation for the organization's CT program to promote prudent and safe use of CT scans.

•Develop comprehensive guidelines and protocols to ensure the safe administration of radiation for all imaging modalities.

•Educate physicians, clinicians and patients about the potential risks of diagnostic radiation. This should include outreach to referring physicians to raise awareness of the issue and to the hospital's policies and procedures regarding dose management.

•Provide comprehensive training for radiation technologists and other relevant staff on the use of diagnostic technology, including the appropriate use of potentially dangerous equipment.

•Facilitate communication among physicians, technologists, medical physicists and staff regarding radiation exposure.

Ensure the right test

•Use other imaging technologies, such as ultrasound and magnetic resonance, to reduce exposure to ionizing radiation whenever one will produce the image quality necessary for the diagnostic information needed.

•Enhance communication between ordering physicians and radiologists to ensure that the right test is ordered based on an individual patient's needs and diagnostic requirements.

•Consider the installation of automated decision support systems to assist in the selection of the appropriate test based on a patient's needs.

Ensure the right dose

•Conduct a periodic check of imaging equipment to ensure that it is functioning properly.

•Perform routine checks of equipment to ensure proper functionality.

•Adopt "As Low as Reasonably Achievable" guidelines set forth by the U.S. Nuclear Regulatory Commission, designed to make sure radiation dose is as minimal as possible for the study being conducted.

•Participate in the "Image Gently" and "Image Wisely" campaigns to ensure proper radiation exposure to both children
and adults.

•Develop appropriate dose ranges for high-volume, high-dose imaging studies.

•Provide resources to physicians and technologists to determine the proper dose based on patient anatomy and size and the purpose of the study.

•Develop a process to review dose protocols on an annual or biannual basis to ensure that protocols are followed.

•Examine cases in which protocols were not followed and provide education to prevent future occurrence.

•Track cumulative dose on the patient's electronic health record.

•Provide patients a medical imaging record card that tracks the type of test performed, the date and location of the test and the radiation dose.

•Join the National Radiology Data Registry to compare organizational performance against regional and national benchmarks.

Source: H&HN research, 2012

Four factors contributing to unnecessary radiation exposure

1 Improper device use.

The rapid pace of imaging technology development makes it difficult for referring physicians, radiologic technologists and radiologists to keep up with all of the changes. As a result, it's not uncommon to see wide variation in practices between organizations and among providers and technologists within the same organization. Education, training and certification programs can assist clinicians in providing high-quality, consistent and safe imaging procedures.

Organizations also should form close partnerships with their vendors to ensure a thorough understanding of the technology and its capabilities.

2 Lack of consensus regarding risk of radiation exposure and appropriate dose.

A lack of consensus exists among clinicians about the dangers of radiation exposure and the proper radiation dose. Again, education, training and certification programs can build understanding about the importance of reducing patients' exposure to unnecessary radiation.

3 Lack of access to patient information.

Ordering physicians may lack the knowledge and access to patients' medical imaging and radiation dose history. Radiation dose should be recorded in a patient's electronic health record and tracked in the radiology information system.

4 Lack of awareness of standard protocols and recommendations.

In some instances, referring physicians may be unaware of the standard protocols and recommendations for imaging procedures. Built-in safeguards and alerts can help, but must be supplemented by education and training. Quality assurance programs regularly should review and update organizations' policies and procedures.

Case Study

MASSACHUSETTSGENERAL HOSPITAL | BOSTON

For more than a decade, Massachusetts General Hospital has focused on providing the lowest dose of radiation for each patient. Among other things, Mass General developed computerized provider order entry and support systems to assist physicians in determining whether conducting a study is in the best interest of the patient. When placing an order, physicians receive a utility score for the test, along with scores for potential alternate tests to determine which test is best based on the patient's age, size, gender and medical condition. "If there is an alternative test, we will try that first," says Dushyant Sahani, M.D., director of computed tomography. The system also alerts physicians if similar tests have been ordered and preformed to avoid duplication of imaging procedures. Safety checks play an important role. Prior to conducting imaging exams, the patient information is checked and double-checked to guarantee that the exam is absolutely necessary. A radiologist "champion" is assigned to oversee CT protocols for each specialty area; and a team of radiologists, technologists and medical physicists monitor and revise protocols on an ongoing basis. As a result of the initiative, Mass General's typical dose levels for CT exams are a minimum 30 percent lower than suggested levels by the National Council on Radiation Protection & Measurements.