Implementation of a multi country CT Dose Management system

Transcription

1 Implementation of a multi country CT Dose Management system Poster No.: ESI-0015 Congress: EuroSafe Imaging 2016 Type: EuroSafe Imaging Authors: K. Katsari 1, R. Illing 2, A. Papachristodoulou 3, C. A. Ciortea 4, V. A. G. Herédia 5, S. Puggina 6, G. Volford 7, X. Boulanger 8, A. Kaczor 9 ; 1 Affidea Budapest/HU, 2 Affidea HQ Budapest/HU, 3 Thessaloniki/ Keywords: DOI: GR, 4 Cluj Napoca/RO, 5 Montemor O Novo/PT, 6 Monselice/IT, 7 University of Szeged Szeged/HU, 8 Fribourg/CH, 9 Euromedic Kielce Kielce/PL Action 3 - Optimisation, diagnostic reference levels, image quality, Action 10 - Improved communication and collaboration of health professionals in radiation protection, Action 12 - Cooperation with international radiation protection initiatives and other stakeholders including IAEA, WHO, ICRP, HERCA, European Commission /esi2016/ESI-0015 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all Page 1 of 16

2 claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 2 of 16

3 Background/Introduction Introduction Computed Tomography (CT) was first introduced in the early 1970s. It quickly became an essential tool for the diagnosis of many medical conditions and the evaluation of treatment progress. Improved technology and the development of helical and multi-detector CT resulted in even broader utilization with a rapid use growth in many countries [1]. Although CT has become a major workhorse of diagnostic medicine, it is a procedure that uses higher levels of ionizing radiation than other x-ray modalities. Concerns about CT radiation began in the early 2000s, focused initially on pediatric CT [2, 3] with subsequent articles raising concern for potential carcinogenesis from medical imaging [4]. Optimization of medical exposure primarily requires that the relevance of each diagnostic examination be justified [5]. If a CT scan is clearly indicated and well ordered, the benefits of are immense and certainly exceed the risks. The general principle we follow in radiology is ALARA: doses should be as low as reasonably achievable, without compromising the diagnostic benefits of the CT procedure. The inherent risks associated with ionizing radiation are an undeniable argument for the radiological community to invest in CT dose management. Affidea, a Dutch holding company and one of the largest healthcare investors and operators in Europe, launched a management strategy of dose and good practice in CT across its network in March of 2014, namely the CT Dose Excellence Campaign. The main goals of the Dose Excellence Campaign are to ensure and improve patient safety, provide unified high quality services and foster a dose awareness culture. Objective The objective of this poster is to introduce the unique Affidea Dose Excellence Strategy implemented in 9 European countries. Page 3 of 16

4 Description of activity and work performed Methods and Materials Designing and implementing a CT Dose Management strategy across 9 countries, for 53 CT systems from 3 vendors, with 20 different CT models, in both the private and public healthcare sectors is a challenging task. In order to achieve this, collaboration among radiologists, medical physicists, technologists, and those tasked with quality improvement and change management is essential. The structure of the teams and their interaction, the communication channels, each team member's responsibilities and tasks, the processes and goals must be clearly outlined and communicated. The data collection from different models of CT systems supplied by different vendors requires a vendorneutral dose tracking software. The dose tracking software assists in the automatic recording and analysis of CT dose metrics, but it is up to the user to evaluate variability between the same protocols, the setting of dose reference levels, benchmarking, the prevention of excessive medical radiation exposure and achieving an evidence-based balance between image quality and dose. Last but not least, an essential element to achieve a comprehensive campaign is a structured communication plan to inform patients and referring doctors of radiation risks and dose management, and to the staff to optimize the processes. The Affidea Dose Excellence Campaign Affidea Dose Excellence Countries The Affidea Dose Excellence campaign was initiated in March of 2014 in 3 countries and 16 CT departments. Today, the campaign has been successfully implemented in 9 countries and 53 CT departments (figure 1). Teams, Communication Channels, Responsibilities and Tasks For the design and implementation of the campaign, multidisciplinary teams have been assigned at Affidea headquarters, country and center level. As external bodies, the dose tracking software team, CT vendor advanced application specialist teams and service providers support the Affidea teams at different levels. Each team and team member has clear responsibilities and tasks to achieve. The structure of the communication channels is designed to facilitate information transfer and avoid any implementation errors (figure 2). Dose Tracking Software Page 4 of 16

5 For the multi-parameter and multivendor data recording and analysis, Affidea chose GE HeathCare DoseWatch software (figure 3). Affidea Standardized Adult CT Protocols An essential part of the campaign was the drafting of the list of 65 standardized adult CT protocols. The CT protocols are categorized by anatomic area and clinical indication. Information in the Affidea protocols list includes acquisition mode, accepted number of exposures, protocol sequence details, DoseWatch mapping ID and 3 rd percentile Dose Reference Levels (DRLs) for CTDI vol and DLP. All departments have unified the CT protocol names, which are based on the clinical indication of the examination, to ensure that the radiographers select the correct protocol, as well as the accurate comparison of protocols between CT systems. Affidea Standard Operating Procedures and Guidelines A set of standard operating procedures and guidelines has been created for the comprehensive implementation of the assigned processes. Standard procedures include; quality control of CT systems, the justification of high dose level alerts, the mapping of site CT protocols to the Affidea Standardized Adult CT Protocols. CT Dose Metrics and Other Parameters Tracked for Analysis The CT dose metrics recorded for analysis are CTDI vol, DLP, SSDE and effective dose. Other parameters that are also recorded are; justification of high dose level alerts, body mass index (BMI), patient age, radiographer initials, number of exposures. Justification, Standardization and Optimization Report A monthly report has been created, in collaboration with the GE HealthCare DoseWatch team, to analyse the data collected and assess compliance of justification of high dose level alerts, examinations performed with standardized protocols and dose levels applied when protocols are followed. The report includes a dashboard for the visual assessment of the 3 parameters, as well as other detailed information (figures 4, 5). The center and country teams review the reports on a monthly basis to decide on corrective actions required to improve the practice. Affidea Dose Reference Levels Affidea DRLs have been set according to international published data from 2012 onwards [6]. Page 5 of 16

6 Optimization of Protocol Parameters Protocols of the same clinical indication and CT model are compared for dose benchmarking. Corrections of protocol parameters are performed for protocols with dose levels above 3 rd quartile DRLs. Further optimization of the protocols and personalized patient care will in the future include BMI, image reconstruction algorithms and parameters, contrast media protocols, dose reduction algorithms and special patient categories. Image Quality and Dose Optimized Protocols To align radiation dose and image quality, the image quality of each protocol in the first quartile with low doses and in the third quartile with high doses is assessed by a panel of disease specialized radiologists using a double blinded rating system. The methodology used for the analysis of the data is Fleiss kappa for interrater reliability, VGA for observer performance evaluation and ordinal regression analysis to combine dosimetric results with image analysis results. Further assessment of the optimized protocols is performed with anthropomorphic phantoms to evaluate low contrast and noise. Education Comprehensive education is provided to radiologists and radiographers on different aspects and expertise levels including MDCT technology, dose reduction algorithms, communication of risk to patients, protocol settings for obese patients, impact of CT protocol parameters on dose and image quality. Affidea Communication Plan KATIA KATSARI Normal 0 false false false EN-US JA X-NONE Brochures with information addressed to patients and referring doctors have been specially created [figures 6, 7]. Administrative personnel, marketing teams and managers have also been trained to address patient questions. Page 6 of 16

7 Images for this section: Fig. 5: Protocols Dose Level Analysis Affidea Page 7 of 16

8 Fig. 6: Patient and referring doctors information brochure Affidea Page 8 of 16

9 Fig. 7: Dose Excellence center poster Affidea Page 9 of 16

10 Fig. 1: Affidea Dose Excellence Countries Affidea Page 10 of 16

11 Fig. 2: Dose Excellence Teams and Communication Channels Affidea Page 11 of 16

12 Fig. 3: Dose Tracking solution GE HealthCare Page 12 of 16

13 Fig. 4: Justification, Standardisation and Optimisation Dashboard Affidea Page 13 of 16

14 Conclusion and Recommendations A clear dose management structure and strategy are crucial when CT protocol optimization and patient safety are concerned. Many different parameters have to be taken into account for a multi country strategy to be implemented, such as each National Health System's rules and country legislation, reimbursement schemes, referral guidelines. Further posters featured in the 2016 European Congress of Radiology by our group can demonstrate that the Affidea Dose Excellence Strategy has been successful in building a dose awareness culture, optimizing practices and protocols, increasing patient safety and collegiality between centers and countries, allowing best practices to cross borders. The accomplishment of best practices is a long and challenging process, but through this process patient safety and the full utilization of state- of-the-art technology will be successfully accomplished. Page 14 of 16

15 Personal/Organisational information Katia Katsari - Affidea Chief Medical Physicist and Dose Excellence project leader Dr. R. Illing - Affidea Chief Medical Officer Affidea B.V. Prins Bernhardplein 200, 1097 JB Amsterdam, The Netherlands affidea.com Page 15 of 16

16 References 1. OECD (2015), Health at a Glance 2015: OECD Indicators, OECD Publishing, Paris J. Mathews & al, Small cancer risk following CT scans in childhood and adolescence confirmed, British Journal of Radiology, Pearce MS, Salotti JA, Little MP, McHugh K, Lee C, Kim KP, et al. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet Aug 4; 380 (9840): Fazel, R., Krumholz, H.M., Wang, Y., Ross, J.S., Chen, J., Ting, H.H., Shah, N.D., Nasir, K., Einstein, A.J., Nallamothu, B.J. (2009) Exposure to Low-Dose Ionizing Radiation from Medical Imaging Procedures. N Engl J Med p European Union. EURATOM. (2013) Laying down the basic safety standards for protection against the dangers arising from exposure to ionizing radiation. Official Journal of the European Union (Directives). 6. Radiation Protection N o 180: Diagnostic Reference Levels in Thirty-six European Countries. Publications Office of the European Union, Page 16 of 16