Experts say technology will only take you so far. Successful dose reduction programs include a number of essential elements and a champion to lead the way.

By Elaine Sanchez Wilson

With peer-reviewed articles spelling out the risks of radiation exposure and increased concern from a more informed general public, healthcare organizations across the country are purchasing the latest in technology to bolster their dose minimizing efforts.

However, experts caution imaging departments to be aware that equipment and software are not the sole components for successful dose reduction programs. Rather, hospitals and health networks must reevaluate their own protocols, educate their medical staff, take the time to reach out to the community, and give special attention to data analysis.

“This is all about culture change, which does not come naturally and often does not come easily,” said Stacey Funt, MD, a Long Island, NY-based clinical radiologist in practice for 18 years and an independent consultant for radiology quality, safety, and clinical integration. Funt has initiated and led radiation reduction task forces in community hospitals, served as clinician liaison, and consults with Accountable Radiology Advisors. “It takes people willing to do things differently. It’s about education and setting up processes that integrate smoothly into the workflow. And it’s about partnering with clinicians to serve as consultants for best practices.”

Getting Started

National publicity surrounding the negative effects of radiation accumulation prompted Houston Healthcare in 2013 to form a dose reduction committee, which stemmed out of the organization’s radiation safety committee. According to Tim Sisco, director of Cardiovascular and Imaging Services, the subcommittee consists of a CT supervisor, radiology supervisor, image services managers from the network’s three campuses, and physicists from contracted group Phoenix Technology. “This committee was developed across our system to improve patient safety by lowering radiation dose,” he said. “The physicists’ involvement was to validate our efforts.”

At Good Samaritan Hospital, Funt recruited an administrator and a technologist who were passionate about dose reduction to help her launch a dose reduction program.

“Anybody who wants to start a radiation dose reduction program needs a champion,” Funt explained. “It took a few people who were interested and motivated to make it all happen.”

The first step the committee took was reviewing and questioning the department’s protocols. “Besides adopting radiation reduction software, there was a lot we could do to minimize patient exposure based on how we used our machines. For example, were we doing multiple phases when we only had to do one phase?” Funt said. “Were we starting in the middle of the lungs when we could have been starting at the lung bases? When we were doing a multiphase CT scan to evaluate a lesion, were we confining additional runs just to the organ of interest rather than the entire abdomen and pelvis? We needed our subspecialized radiologists involved to optimize the scope of protocols to be sure we were only doing what was necessary.”

Not all radiologists were initially on board with the proposed changes that Funt and her colleagues recommended. For example, one radiologist was uncomfortable cutting out the lung bases for the hospital’s follow-up renal stone protocols, which were revised to start at the top of the kidneys.

“As radiologists, we were focused on the best quality diagnostic images with the highest resolution and minimal noise,” Funt said. “Now, we are changing our mindset in some clinical situations to see things well enough to make an accurate diagnosis without needing the magnificent visual experience we had before. For example, when you’re looking for lung nodules, for renal stones, or at parts of the body that inherently have a lot of contrast, you can tolerate a little bit more noise than you did before.”

Meanwhile, Chris Tomlinson, director of radiology and executive director of Radiology Associates at the Children’s Hospital of Philadelphia (CHOP), recalled how dose reduction initiatives have been taking place for years at the institution, via an enterprise-wide radiation safety committee.

“Before this was cool and in vogue, we were doing this,” Tomlinson said, adding that CHOP had written an article in 2005 for the Radiological Society of North America and even before then had required its radiologists to be in a certain mean for safe fluoroscopy dose. “It’s so important because the radiation effects on kids are so much more impactful. And I think that’s why most of your pediatric hospitals have been doing this for a long time.”

According to Tomlinson, CHOP’s committee includes a medical physicist, modality management, and lead supervisors in each area, including the lead technologists for CT, IR, and nuclear medicine, radiologists, cardiologists, and biomedical engineers. It also invites others who fall outside the realm of radiology and cardiology, such as dental, urology, environmental health and safety, risk management, and radiation safety officers. “A strong infrastructure with the right people there allows you to deal with policies and procedures,” he said.

Technology and Processes Matter

Strategic equipment purchases from Carestream and Toshiba America Medical Systems were pivotal in optimizing—and quantifying—Houston Healthcare’s dose reduction efforts across its three campuses: Houston Medical Center, Perry Hospital, and the Pavilion Diagnostic Center. For example, a special monitoring QA program from Carestream allows management to provide appropriate feedback to the staff.

Additionally, the network was one of the first organizations in the country to implement the Toshiba Protect program for CT dose reduction. Through this program, Toshiba actually assists in the dose capture and evaluation, as well as offers customized recommendations for protocol changes and adjustments to achieve significantly lower radiation dose.

“We have been actually seeing an average dose reduction of 50% on our chest and abdomen CT scans, and we have achieved a 40% to 55% less dose on CT abdomen/pelvis scans as compared to the national American College of Radiology (ACR) reference level,” Sisco said, explaining that the reference level set by the ACR is for a 70 kg (approximately 150 pound) patient. “Phoenix Technology has validated all of our results and has concluded we achieved a 65% less dose compared to our prior CT protocols across all of our sites. Plus, we have the same equipment across our facilities, so we were able to standardize our protocols on all of our imaging machines, which are all achieving this reduced radiation of dose.”

At CHOP, delivering the lowest dose from the newest equipment is number one in its decision criteria for any radiation-bearing piece of equipment, Tomlinson said.

But while having the right technology is crucial, so too is workflow, he pointed out. “I think it is important to differentiate a program as a collection of people and projects versus a program in terms of an IS application,” he said. “A lot of people are looking at the industry and all these dose tools and say, ‘I’m going to buy one.’ That’s great, but that’s just a tool for a program and one IS tool doesn’t make up a program. It’s really about the processes, the structure you have, to support these initiatives outside of an IS system.”

Funt agrees that iterative reconstruction and radiation reduction software is not enough. “Just because the machine is putting out the least amount of radiation that it can doesn’t mean that clinicians are ordering a study for the correct reason,” she said. “It doesn’t mean that patients are prepped and positioned correctly so we don’t have to scan them a second time. We realized that there was much more consciousness-raising that we needed to be doing.”

External and Internal Outreach

Experts say that radiologists and technologists need to be deeply involved in any dose-reduction initiative.

For example, at Good Samaritan, Funt formed a physician outreach education department, delivered various presentations relating to radiation dose aimed at clinicians, and made herself available to speak with outside departments, such as the emergency department, about the risks of radiation exposure. She also created a pledge campaign, adapting the Image Wisely pledge, and asked all radiologists, technologists, and nurses to sign. Funt described how this seemingly simple gesture empowered an x-ray tech to speak up, after noticing that two different doctors had ordered a CT scan and an x-ray for the same complaint; the extra exam was afterward canceled.

At Houston Healthcare, x-ray machines were recalibrated to achieve lower dose acquisition while achieving maximum image quality needed to effectively diagnose patients. “We constantly work with our radiologists as we monitor and improve dose,” Sisco said.

Equally important in dose-reduction campaigns is the patient education component. Houston Healthcare frequently meets with community groups and hosts discussions around radiation dose. CHOP keeps a variety of pamphlets and information in its waiting areas, and patient communication is made a priority. “Our technologists have talking points to help parents understand dose in relation to environmental factors, like background radiation or flying in cross-country flights,” Tomlinson said. “We help them frame the risk in terms of the outcome, of why we are doing the study. The problem is a lot of patients don’t understand the unit of measure in radiation terms. A millisievert doesn’t mean anything to most people.”

With the help of a Ukrainian software company, Funt took it upon herself to create a free mobile app (found at myimagingrecords.com) for patients to track their dose accumulation, including mammograms and dental x-rays. “I personally believe that patients must be engaged in their own healthcare to have the best care and the least amount of waste,” Funt said. “As patients become more involved, they can be their own advocates as well. Most doctors are very well meaning, but it takes an integrated team collaborating together to get the best outcomes.”

Quantification Matters

Data tracking, including comparing one’s dose data to the ACR’s various dose index registries, is another necessary step in launching a successful program. For example, fluoroscopy equipment at CHOP is set up with visual cues to ensure that the lowest dose is being administered, Tomlinson said. “We used a red/yellow/green mechanism to make sure that things were reset and ensure that we started at the lowest dose and only worked upward when we needed to,” he said. “Those visual cues really affected the dose usage of those pieces of equipment. We saw that the dose, when you accumulated it across all patients, went down aggregately because of this change. And we started to track that and put it into our reports.”

Funt pointed out that not only can departments compare their data to the national average, they also can compare themselves to themselves. “Besides comparing themselves to the national average, they can look at what they are doing today and pick similar studies from before they started their efforts to document how changes to protocols and practices have had an effect,” she said, adding that departments also could examine the percentage of negative studies ordered by physicians to identify outliers. Additional education may help remedy those situations.

Words of Advice

The experts had no shortage of advice for other health providers seeking to launch dose-reduction campaigns at their own institutions: Seek out low-dose technologies that meet organizational priorities, set realistic goals, join forces with administration, develop clear plans before implementation, ask current vendors how they can minimize dose based on existing equipment, and align radiologist compensation to reducing dose.

Ultimately, dose reduction can result in huge benefits for all parties involved— positive marketing for hospital management, a sense of inter- and intra-collaboration among clinicians, and, most importantly, quality care for patients. “External affairs and administration were very happy with the publicity we could give the hospital, especially since radiation safety has been so prevalent in the media,” said Funt. “It demonstrated our commitment to patient care and continued to show the value of radiologists, that we are not just marginalized professionals sitting in a dark room churning out reports. We received accolades, but more than anything else, we knew that we were doing the right thing for our patients.”

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Elaine Sanchez Wilson is a contributing writer for Axis Imaging News.

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Tracking Tools to Check Out

DoseWatch from GE

GE Healthcare unveiled its web-based DoseWatch software in 2011, allowing providers to capture, track, and report radiation dose directly from the modality, vendor agnostic. DoseWatch does not restrict data acquisition to strictly DICOM Radiation Dose Structured Report (RDSR), but rather can collect related information from sources like image headers, MPPS, and Optical Character Recognition (OCR). This flexible configuration results in broad tracking of data across the enterprise, including older equipment. Its latest version of the patient radiation dose monitoring solution delivers a new, intuitive user interface. It also includes a dose comparison analysis tool that enables customers to compare dose between facilities, across health systems, and among protocols. Other features include an automated notification management system, scheduled studies worklist, study overview and details, CT acquisition quality review, size-specific dose estimate, and incidence map, among others.

DoseMonitor Software from PHS Technologies

In 2012, PHS Technologies Group, a division of PACSHealth, announced expanded functionality for its DoseMonitor software solution in an effort to provide value, enhance patient safety, and help providers to meet increasingly stringent regulations. The single-server, browser-based 2.0 version is equipped with full multimodality support, including mammography, direct radiography, and angiography, in addition to CT. It also offers new reports, such as dose by technologist by procedure, dose by physician by procedure, mammography reporting (organ and Mean Glandular dose), and age range support for alerts and notifications. With its full support for VMware-based implementations, hospitals and health systems can virtualize hardware on an existing server. The solution automates data capture from the PACS and can directly report it to the RIS, EMR, or the ACR’s Dose Index Registry.

DoseTrack from Sectra

Last year, medical imaging IT company Sectra rolled out a web-based dose monitoring product called Sectra DoseTrack, designed to collect, store, monitor, and compare patients’ radiation exposure from medical imaging procedures. The solution ensures that radiation dose is kept as low as reasonably achievable. It can be configured to automatically track data from all connected modalities, which allows for easy comparison of radiation levels at the modality, examination, or patient level. What’s more, Sectra DoseTrack can export data for reporting to regulatory authorities. It supports both the IHE Radiation Exposure Monitoring profile and the DICOM MPPS standard, along with DICOM Radiation Dose Structured Report (RDSR), Optical Character Recognition (OCR), and manual input. Virtually any modality can connect to the system, resulting in a comprehensive enterprise-wide solution.

Dose Tracking System from Toshiba

At RSNA 2013, Toshiba America Medical Systems revealed its brand-new Dose Tracking System (DTS), billed as the industry’s first live monitoring solution for skin radiation exposure. Cleared for all exams, but not yet available on all Infinix-i models, DTS displays real-time and cumulative radiation exposure via an intuitive, color-coded indicator on a 3D visual representation of the patient. By showing where radiation is being administered on the patient’s body in real time, clinicians are better able to manage dose and minimize locally concentrated high exposure. DTS also enables users to store dose information for a given patient and procedure in a report format, which can record peak skin dose (PSD), total fluoroscopy time, total radiography time, as well as snapshots of the skin dose distribution.

–E. Sanchez Wilson