8/1/2017. Financial Disclosures. Dose Tracking at MGH. How Dose Tracking Affected Protocol Optimization in a Tertiary Quaternary Healthcare Center
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1 How Dose Tracking Affected Protocol Optimization in a Tertiary Quaternary Healthcare Center Mannudeep K. Kalra, MD Webster Center for Quality and Safety Massachusetts General Hospital Harvard Medical School Financial Disclosures Research Grants Siemens Healthcare Toshiba (Canon) America Medical Systems AHRQ (National Institute of Health) Dose Tracking at MGH Software Radimetrics, Bayer ACR Dose Index Registry 1
2 Tracking and Cracking: Personnel Medical Physicist (PhD: Lead) Dose tracking (Radimetrics) ACR DIR CT Quality Assurance Manager (RTR - CT) Protocol maintenance ADULTS...CT CTDI vol Notification Value Head 80 (16 cm) Neck AND C -Spine 30 (32 cm) Neck CTA 50 (32 cm) Abdomen-Pelvis AND L-Spine 30 (32 cm) Chest AND T-Spine 30 (32 cm) Extremities 30 (32 cm) Brain Perfusion 600 (16 cm) Cardiac/Vascular Prospective (sequential) 50 (32 cm) Cardiac/Vascular Retrospective (spiral) 150 (32 cm) Children. CT Abdomen-Pelvis AND L. Spine Chest- T. Spine Extremities Head Neck AND Spine Cardiac/Vascular Prospective (sequential) CTDI vol Notification Value 20 (32 cm) 20 (32 cm) 20 (32 cm) 40 (16 cm) 40 (16 cm) 50 (32 cm) 2
3 Scanner Notification Reports Weekly/Quaterly review of Dose tracking Medical Physicist CT QA manager Quarterly review of Doses from ACR DIR Medical physicist Radiology Quality and Safety Committee Issues with Reports: Radiologists Abdominal Cardiac and Vascular Emergency Chest Neuroradiology Separate personnel for Adults & Children Pediatrics Musculoskeletal 3
4 MGH vs DIR MGH vs DIR MGH versus DIR 4
5 Cardiac CT Dose Tracking Protocols Routine chest with IV contrast Routine chest without contrast Lung nodule follow up Diffuse lung disease protocol Pulmonary Embolism Tracheal protocol Clinical Reasons Masses, infections, trauma to lungs, mediastinum, & pleura Elevated creatinine for above, Follow-up nodule in pt s with CA Follow up nodule without known malignancy For diffuse lung diseases e.g. Sarcoid, bronchiolitis obliterans, ILD, pulmonary fibrosis, Suspected or known pulmonary embolism Tracheobronchomalacia Tracheal stenosis Sequence of Dose Utilization 1. Appropriateness Just Right Indication with Decision Support 2. Indication based dose optimization CT protocols based on clinical indications 3. Patient size based dose adjustment Separating children from adults Automatic exposure control Automatic tube potential selection Kalra et al. Radiographics
6 Issues with Dose Tracking Variety of CT scanners Variety of CT protocols Multi-phase or multiple-run CT Bariatric patients Hardware Arms in wrong places- by side of body or head Scanners 24 CT GE Philips Siemens Sorting Protocols Multiple protocols Multiple nomenclature 6
7 CTA- Head and Neck DLP above the 75 th percentile in ACR DIR Non contrast CT Post contrast arterial phase Delayed phase Trouble shoot Reduce kv Reduce dose for non-contrast and delays Bariatric Issues CT Myelogram Frequent culprit Particularly with hardware 7
8 High Frequency Issues 4. Bariatric patients Dose Notification for Head CT Cervical Spine (CTDI vol 36 mgy)? Too long cervical spine CT Large patient with large shoulders Dose modulation or AEC 8
9 CTDIvol 68 mgy Too early start: 12 sec Too long continued: 49 seconds CT Dose Monitoring Physics & CT QC teams: Quarterly Dose Review Lessons on Managing Dose Continuous dose monitoring while maintaining quality Tailoring radiation dose to clinical indication Adapting doses to patient body habitus CT radiation dose will exceed the notification values and certainly can be higher than DRLs Reference: Kalra MK et al. CT Radiation: Key Concepts for Gentle and Wise Use. Radiographics Oct;35(6):
10 Summary from MGH Dose Tracking Boss is always right Medical physicists better at tracking than MD Dose tracking and optimization are dynamic and ongoing Teamwork is a must Team work: Medical Physicist (lead), CT RTR, Radiologists Dose tracking is the right thing to do Helps identify issues Helps fix issues (some) Not all problems are fixable!! Acknowledgement Medical Physicists at MGH Bob Liu, PhD; Kai Yang, PhD; Matthew Delorenzo, PhD CT technologists at MGH Cristy Savage, CT QA manager CT protocols in-charge radiologists 10
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