Utilization of a Patient Dose Tracking and Monitoring System to Modify CT Protocols and Lower Patient Doses
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1 Utilization of a Patient Dose Tracking and Monitoring System to Modify CT Protocols and Lower Patient Doses Randell Kruger, Ph.D. Medical Physics and Radiation Safety Marshfield Clinic Health Systems
2 Learning Objectives 1. Summarize The Joint Commission (TJC) diagnostic imaging requirements 2. Review patient dose tracking and monitoring methods and systems 3. Discuss applications and implementation of a CT patient dose tracking and monitoring system and how it can used to lower patient dose
3 Presentation Outline Introduction and Requirements CT Patient Dose: Monitoring and Alerts CT Patient Dose: External Benchmarks CT Dose Case Study: Adult Head Exams CT Dose Case Study: Pediatric Head Exams Discussion and Conclusions Questions?
4 Introduction and Requirements
5 Introduction and Requirements Factors contributing to this effort The Joint Commission (TJC), Diagnostic Imaging requirements updated to include CT dose CT protocol review committee efforts CT patient dose monitoring and alert system recently procured by our organization Participation in (and feedback from) the American College of Radiology (ACR) National Radiology Data Registry (Dose Index Registry, DIR)
6 Introduction and Requirements
7 Introduction and Requirements Key elements of TJC requirements Determine expected dose index ranges Review and analyze incidents that exceed range Compare incidents to external benchmarks Other requirements and organizations ACR CT accreditation program State regulations? Others (CMS, etc.)
8 Introduction and Requirements F. Mettler ICRP 2011
9 Introduction and Requirements Image Gently and Image Wisely Campaigns imagegently.org and imagewisely.org Adjust and review pediatric CT protocols to meet clinical need Radiologist interest and participation
10 SAM Question? Please use the Poll Everywhere app or website to answer the SAM question
11 SAM Question? The Joint Commission requires organizations to review and analyze incidents where the radiation dose index from diagnostic CT examinations that exceeded dose index ranges identified in imaging protocols. These incidents are then compared to. A. expected, ACR benchmarks B. ACR, external benchmarks C. expected, external benchmarks D. ACR, ACR benchmarks Reference: TJC Diagnostic Imaging Requirements, Performance Improvement Standard PI
12 SAM Question?
13 CT Patient Dose: Monitoring and Alerts
14 CT Patient Dose: Monitoring and Alerts Radimetrics (Bayer HealthCare LLC) CT protocol dose ranges established by diagnostic medical physicist (DMP) Based on reported statistics for patient DLP values Alert levels set to 2x Std Dev of mean, reviewed annually Patient dose alerts monitored weekly and reviewed by DMP
15 CT Patient Dose: External Benchmarks
16 CT Patient Dose: External Benchmarks External benchmark employed was the ACR National Radiology Data Registry (NRDR) Dose Index Registry (DIR) Facilities enroll in NRDR send their CT data to the DIR and receive quarterly feedback Diagnostic Reference Levels (DRL) and Achievable Doses (AD) for ten adult CT exams
17 CT Patient Dose: External Benchmarks Facility compared to ACR DIR values Top 10 adult and pediatric exams Identifies outliers
18 CT Patient Dose: External Benchmarks Evaluated 5 CT exam protocols One exam was a significant outlier Head Brain w/o
19 CT Dose Case Study: Adult Head Exams
20 CT Dose Case Study: Adult Head Exams CT protocol review committee selected adult heads Committee: radiologist, management, DMP and RTs Protocol modifications reviewed, evaluated and tested Sites 2, 3 and 7 are hospitals with a dedicated ED CT CT Head Brain WO IVCON Exams CT HEAD WO IVCON Distribution per CT scanner, total = 1,139 Site 1 Site 2 Site 3 Site 4 Site 5 Site 6 Site 7 Site 8 Site 9
21 CT Dose Case Study: Adult Head Exams Adult head w/o contrast CT protocol Toshiba Acquilion One CT scanners Five CT scanners total, all 4-5 years old Helical scan, without ma modulation Image quality reviewed/monitored by radiologist Achieved a target DLP of <1109 mgy-cm Initial data: CTDIvol = 69.5 mgy, DLP = 1271 mgy-cm Iteration 1: CTDIvol = 63.7 mgy, DLP = 1167 mgy-cm Iteration 2: CTDIvol = 60.8 mgy, DLP = 1115 mgy-cm Iteration 3: CTDIvol = 57.9 mgy, DLP = 1064 mgy-cm
22 CT Dose Case Study: Adult Head Exams
23 CT Dose Case Study: Adult Head Exams Adult head w/o contrast CT protocol Siemens Sensation 64 and 40 CT scanners Four CT scanners total, all 7-15 years old Helical scan, without ma modulation Image quality reviewed/monitored by radiologist Achieved a target DLP of <1109 mgy-cm Initial data: CTDIvol = 70.5 mgy, DLP = 1354 mgy-cm Iteration 1: CTDIvol = 59.9 mgy, DLP = 1172 mgy-cm Iteration 2: CTDIvol = 56.4 mgy, DLP = 1108 mgy-cm Iteration 3: CTDIvol = 54.9 mgy, DLP = 1080 mgy-cm
24 CT Dose Case Study: Adult Head Exams
25 CT Dose Case Study: Pediatric Head Exams
26 CT Dose Case Study: Pediatric Head Exams Comparison of reduced adult head to pediatric head protocols resulted in another optimization effort Adult head doses approximately the same as pediatric heads
27 CT Dose Case Study: Pediatric Head Exams Pediatric optimization effort started August 2017 Reduced CTDIvol by 10%, infant protocol not reduced
28 Discussion and Conclusions
29 Discussion and Conclusions Radiation dose optimization JACR, October 2017 Eric Gingold, Ph.D., Radiology Dept., Thomas Jefferson University How can DMP guide optimization? Work closely with radiologists to gradually ratchet down doses of imaging protocols that are identified as potential opportunities for optimization. essential to achieve an image noise level that radiologists feel comfortable with.
30 Discussion and Conclusions Discussion (lessons learned) The DMP Collect, review, evaluate and analyze data Team leader and guide of optimization effort The radiologist(s) Clinical image quality acceptability (SNR variability) Compensation, medical and legal considerations The CT technologist (team lead) A valuable optimization implementation resource
31 Discussion and Conclusions Conclusions (the good, bad, and ugly) The good Limited adult and pediatric CT dose optimization Reduced Adult head DLP by 11.4% for system The bad Did not achieve targeted values on all scanners Project black hole effect time, resources, etc. The ugly Radiologists (one really) directed return to original parameters for three Siemens CT scanners at end of effort
32 Questions?
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