Session 83X Dose Management: Patient and Staff Radiation Safety in Radiology

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1 Prepared for the Foundation of the American College of Healthcare Executives Session 83X Dose Management: Patient and Staff Radiation Safety in Radiology Presented by: Bert Van Meurs Christoph Wald, MD

of Radiology at Lahey Hospital & Medical

University Medical School BERT VAN MEURS

3 Dose Management: Patient and Staff Radiation Safety in Radiology Setting up a comprehensive dose management program Faculty CHRISTOPH WALD Chairman, Dept. of Radiology at Lahey Hospital & Medical Center, Professor of Radiology, Tufts University Medical School BERT VAN MEURS Business Leader, Image Guided Therapy, Philips 2 1

4 Disclosure of Relevant Financial Relationships The following faculty of this continuing education activity has no relevant financial relationships with commercial interests to disclose: Bert Van Meurs The following faculty of this continuing education activity has financial relationships with commercial interests to disclose: Christoph Wald, MD, PhD Philips Health Tech Honorarium Clinical Advisory Board 3 Learning Objectives Understand the risk of unnecessary radiation exposure that can adversely impact your staff and your patients. Understand Joint Commission radiology process flow and quality performance standards that may require new ways of working for healthcare providers. Learn how to set up a comprehensive dose management plan. 4 2

5 Agenda Radiation Safety 101: Understanding risk and benefits associated with radiology imaging New standards/regulations for dose management Manufacturer and care provider roles Establishing a culture of radiation dose management in healthcare Innovation in lowering radiation exposure to patients and staff The future of diagnostic imaging 5 Radiation Safety 101 Appropriateness benefit>risk if the exam is medically necessary Justification which radiology exam is most suited for patient Optimization lowest dose for that patient and exam pairing 6 3

Radiation Safety 101 Exposure is the output of the X-ray machine Dose is the radiation X-ray energy the patient s body actually absorbs CTDIvol is a measure of dose output from a CT scanner, NOT what

There Interventional are Occupational 2 main models radiology of risk: physicians Stochastic Radiosensitivity and receive Deterministic more Radiosensitivity Hazards is the relative susceptibility of

6 Radiation Safety 101 Exposure is the output of the X-ray machine Dose is the radiation X-ray energy the patient s body actually absorbs CTDIvol is a measure of dose output from a CT scanner, NOT what the patient really gets CT phantoms are plastic standardized size objects used to calibrate machines 7 What is the Risk of Radiation Exposure? There Interventional are Occupational 2 main models radiology of risk: physicians Stochastic Radiosensitivity and receive Deterministic more Radiosensitivity Hazards is the relative susceptibility of cells, There radiation are two dose models than of risk nuclear when talking power about plant human workers exposure per to radiation tissues, in organs general. Stochastic or organisms means to that the exposure harmful effect of year Issues on Related average. to 1 to any amounts of radiation ionizing could radiation. be harmful Radiation (a Some matter Dose organs of and probability). are more Deterministic Exposure Risk means that we do understand limits of exposure before health effects radiosensitive than others, such as the eye lens, Overscanning reproductive Understanding exposure organs to patients. and the lungs. Cancer Risk happen (like skin reddening). This is why we must justify and optimize 8 4

7 What is the risk? Occupational Hazards Radiosensitivity Issues Related to Radiation Dose and Exposure Risk Overscanning Understanding Cancer Risk 9 What is the risk? Interventional radiology physicians receive more radiation dose than nuclear power plant workers per year on average

What is the risk? Radiosensitivity is the relative susceptibility of cells, tissues, organs or organisms to the harmful effect of ionizing radiation.

8 What is the risk? Radiosensitivity is the relative susceptibility of cells, tissues, organs or organisms to the harmful effect of ionizing radiation. Some organs are more radiosensitive than others, such as the eye lens, reproductive organs and the lungs. 11 What is the risk? Interventional fluoroscopy 7% Medical X ray 5% Consumer 2% Nuclear Medicine 12% 24% OF PUBLIC EXPOSURE DUE TO CT EXAMS Computed Tomography 24% Terrestrial background 3% Internal Background 5% Space background 5% Radon 37% Ref: NCRP

9 What is the risk? There are 2 main models of risk: Stochastic and Deterministic There are two models of risk when talking about human exposure to radiation in general. Stochastic means that exposure to any amounts of radiation could be harmful (a matter of probability). Deterministic means that we do understand limits of exposure before health effects happen (like skin reddening). This is why we must justify and optimize exposure to patients. 13 Interventions to Reduce Dose Joint Commission Requirements CMS MACRA payment program American College of Radiology Appropriateness Criteria California SB AB510 CT Dose Reporting Texas Administrative Code 25 TAC CT Protocol Committee Image Wisely/Gently Awareness Program Medical Imaging & Technology Alliance (MITA) XR 29 Standard Optimizing scanning protocols at Lahey Clinic Value of delayed-phase images Renal stone patients example 14 7

10 How Are Manufacturers Helping to Reduce Dose? Manufacturers realize that non-x-ray procedures are safer than those with X-ray, for example using MR or ultrasound We must be careful, however, that we are not sacrificing clinical excellence by trading radiation exposure to the patient for inferior clinical results Innovation is key manufacturers are now experimenting with adding tools like ultrasound to surgical catheters gaining even better results and eliminating radiation exposure Critical that manufacturers partner with healthcare providers to drive meaningful innovation 15 Joint Commission Requirements Imaging equipment testing and maintenance Annual education for staff supporting CT and MRI services Minimum qualifications for medical physicists Managing MRI safety risks Data collection on MRI incidents and CT radiation dose data CT protocol management Documentation of CT radiation dose 16 8

Challenging the Gold Standard While there is no doubt concerning the

simple to benchmark, The time is now for manufacturers, regulators and

providers just impact to work radiologists together and to develop

standard but for also imaging realistic the has hospital been and meaningful

justification of the procedure and second, management of dose to that

11 Challenging the Gold Standard While there is no doubt concerning the critical role radiology has in the patient care experience, it is not always simple to benchmark, The time is now for manufacturers, regulators and measure and improve diagnostic imaging practices healthcare This doesn t providers just impact to work radiologists together and to develop radiologic and Thus implement far, technologists, the gold cost-effective, standard but for also imaging realistic the has hospital been and meaningful first, c-suite! justification of the procedure and second, management of dose to that specific programs to monitor radiation dose. patient 17 EMBED VIDEO HERE Establishing a Radiation Safety Program RADIOLOGISTS/ TECHNOLOGISTS MANUFACTURERS PATIENTS 18 9

12 Radiologist Role Make decisions about appropriateness When applicable, engage clinician about possible alternatives Determine how the exam will be done Continuously work to find the balance between radiation dose risk and image quality 19 Technologist Role Understand the equipment Translate the ordered exam, unless done by a radiologist Either receive or pick the imaging protocol, and how the scan is to be done Dial in exposure parameters either according to standard protocol or for each patient 20 10

Manufacturer Role Support programs that help hospitals comply with new standards Develop software

with other manufacturers to create harmonized standards Train users on new technology 21 Patient

Help providers by being transparent and informative about care received Educate themselves on basic

13 Manufacturer Role Support programs that help hospitals comply with new standards Develop software for dose monitoring and tracking Establish partnerships that can offer overarching support Work with other manufacturers to create harmonized standards Train users on new technology 21 Patient Role Question the medical appropriateness of exams Where possible, ask for an alternative modality Help providers by being transparent and informative about care received Educate themselves on basic terminology Yes, I had a CT scan last week. Could you request those images from the other hospital? 22 11

14 Empowering Clinicians to Make Data-driven Decisions Interaction Interaction with EMR with systems will Upgrading allow dose tracking It is important for radiology practitioners to view solutions EMR, to update PACS important patient Equipment demographics retrospective such Older One as of X-ray age the and latest equipment, patient weight advances exposure critical even in ten data for dose the years to tracking look analysis old, for is of has not dose trends (both favorable optimization. Increasing and Connectivity unfavorable). suitable been vendor-agnostic to (in some and Interoperability cases) software display that or can send track out Part of the radiology within quality the Hospital system IT should be patient Interoperability radiation radiation dose within dose PACS the information Network systems entire hospital allows to the clinicians enterprise hospital to IT regular analysis of data to ensure expected identify dose down to the individual exam or cumulative outcomes level Vendor-Agnostic are regardless met, systems and strike and of directly from a PACS image Analyze modality. EMR. a balance a huge Radiation between jump forward clinical image Software quality and radiation Exposure exposure. History in patient care. 23 Empowering Clinicians to Make Data-driven Decisions Interaction with EMR, PACS Upgrading Equipment Increasing Connectivity and Interoperability within the Hospital IT Network Vendor-Agnostic Software Analyze Radiation Exposure History 24 12

15 Empowering Clinicians to Make Data-driven Decisions Interaction with hospital Electronic Medical Record systems is vital to patient records being updated with radiation exposure records. Interoperability with PACS systems allows clinicians to identify patient radiation exposure by exam. 25 Empowering Clinicians to Make Data-driven Decisions Older X-ray equipment, even ten years old, may not be suitable to display or send out patient radiation dose information to the hospital IT systems. Older systems also may expose patients to higher levels of radiation

16 Empowering Clinicians to Make Data-driven Decisions One of the latest advances in dose tracking has been vendor-agnostic software that can track radiation dose within the entire hospital enterprise regardless of modality. 27 Empowering Clinicians to Make Data-driven Decisions It is important for radiology practices to view retrospective patient exposure data to look for trends (both favorable and unfavorable). Part of the radiology quality system should be regular analysis of data to ensure expected outcomes are met, the balance between clinical image quality and radiation exposure

17 The Future of Diagnostic Imaging Health systems can be empowered in analyzing and acting upon data trends in their radiology departments The future of using X-ray and radiation may go away! Sub-milliSievert imaging is real and will push cancer risk into negligible ranges The LNT model (Linear No Threshold) may stay as the model for risk, but it will be greatly reduced with new technology May be left with just a few exams that have high dose The technology may eliminate cancer risk in patients 29 Faculty Biography & Contact Info Dr. Wald serves as the Executive Chair of the Department of Radiology at the Lahey Clinic, responsible for Operations of this multispecialty independent academic medical center imaging department with 38 staff, 20 residents, 350 employees performing approximately 360,000 exams per year at three sites. He has also been the Vice Chair for the Department of Medical Education and Chair of the Graduate Medical Education Committee at the Lahey Clinic, responsible for the oversight of the over 20 training programs and is an elected member of the Lahey Clinic Board of Governors/Medical Executive Committee. Dr. Wald specializes in advanced image post processing, has been integrally involved in the development of computer assisted live donor liver transplant planning methods which have become state of the art worldwide. Christoph.Wald@Lahey.com 30 15

18 Faculty Biography & Contact Info Bert van Meurs is Senior Vice President and CEO for the Business Group Image Guided Therapy (IGT) at Philips. Leading a group of employees, he is responsible for developing a strategy for Philips to become a therapy and device company. Bert has 30 years of proven leadership in Healthcare, where he developed a customer-focused organization that is results oriented. He has a strong professional attitude towards the business, where living the values, being passionate about developing clinical solutions with a strong customer focus and taking care of talented people are his most important leadership competencies. He began his career at Philips in 1985 and worked in various leadership positions in R&D, Clinical Science, Marketing and Sales. He has a record of accomplishment in e.g. X-Ray, Medical Imaging, Radiology, Digital Imaging and Innovation Management. Bert.van.Meurs@Philips.com 31 Bibliography/References 1. Chida K, Kaga Y, Haga Y, Kataoka N, Kumasaka E, Meguro T, Zuguchi M. Occupational Dose in Interventional Radiology Procedures. American Journal of Roentgenology. 2013;200(1):

created by high-voltage devices Examples include medical and dental x-rays, light, microwaves and nuclear energy

created by high-voltage devices Examples include medical and dental x-rays, light, microwaves and nuclear energy What is radiation? Radiation is energy emitted from a source, that travels through space and can penetrate matter. Listed below are two types that we are exposed to and contribute to our overall radiation