JUSTIFICATION PROTOCOLS FOR CT SCANNING ALBURY WODONGA HEALTH WODONGA CAMPUS

JUSTIFICATION PROTOCOLS FOR CT SCANNING ALBURY WODONGA HEALTH WODONGA CAMPUS

JUSTIFICATION PROTOCOLS FOR CT SCANNING INTRODUCTION: In accordance with the Victorian Radiation Act 2005 Wodonga Medical Imaging, Albury Wodonga Health Wodonga Campus (AWHWC) requires all medical imaging referrals that will use medical radiation, to be justified and optimised. WHY ARE GUIDELINES AND REFERRAL CRITERIA REQUIRED? A useful investigation is one in which the result positive or negative will alter management or add confidence to the clinician s diagnosis. A significant number of radiological investigations do not fulfil these aims and may add unnecessarily to patient irradiation. The chief causes of this are: Repeating investigations which have already been performed. Investigating when the results are unlikely to affect patient management. Investigating too often. Requesting the wrong investigation. Failing to provide appropriate clinical information and questions that the investigation should answer. Over-investigating. SCOPE: This document provides specific protocols that should be applied to medical imaging referrals prior to a Computerised Tomography (CT) examination. ROLES AND RESPONSIBILITIES: It is the responsibility of the Radiation Medical Practitioner to define whether a CT examination is justified. It is the role of the Operator to assess a referral and determine whether the scan falls within the criteria of the generic justification protocol or whether it should be justified on an individual basis. DEFINITION OF JUSTIFICATION: A radiation procedure is justified when it is determined that the radiation exposure will produce sufficient benefit to the exposed individual to offset the risk associated with the radiation exposure. In determining the net benefit from a radiation procedure, the Radiation Medical Practitioner must take into account clause 3.2.2 of the Code. JUSTIFICATION PROCESS: Justification of CT examinations can be on the basis of generic justification OR on an individual basis. In both cases the definitions are determined by the Radiation Medical Practitioner. As part of the justification process the Radiation Medical Practitioner should: communicate directly with the referrer to seek clarification if the referral is: Inappropriate. Ambiguous. Would lead to a radiation exposure that does answer the clinical question being posed. The Radiation Medical Practitioner should where it is clinically appropriate: Substitute other imaging tests that do not use ionizing radiation. Modify the examination. Cancel the examination. Limit the procedure scope, eg: limit number of phases. Communicate decisions with the referrer. ALBURY WODONGA HEALTH OTH0059 Page 1

JUSTIFICATION PROTOCOLS FOR CT SCANNING Paediatric CT Referrals (16 years and under) All Outpatient Paediatric CT referrals MUST be Justified and Optimised by the Radiation Medical Practitioner. Any inpatient Paediatric CT referrals MUST have documented approval from: FACEM Paediatric Team Any Consultant ALBURY WODONGA HEALTH OTH0059 Page 2

JUSTIFICATION PROTOCOLS FOR CT SCANNING GENERICALLY JUSTIFIED CT EXAMINATIONS: CT Head 4 CT Facial Bones / Sinus. 5 CT Soft Tissue Neck... 6 CT Cervical Spine 7 CT Lumbar Spine. 8 CT Extremities.. 9 CT Chest. 10 CT Chest (High Resolution). 11 CT Coronary Angiogram.. 12 CT Abdomen (with IV Contrast). 13 CT Abdomen (Non Contrast)... 14 CT Neck / Chest / Abdomen / Pelvis +/- Brain.. 15 CT Pulmonary Angiogram 16 CT Colonography.. 17 EXAMINATIONS JUSTIFIED ON AN INDIVIDUAL BASIS:. 18 CT Renal (multiphase) CT Liver (multiphase) CT Angiogram (any area excluding CT Pulmonary Angiogram and CT Coronary Angiogram) CT Pancreas (multiphase) CT Thoracic Spine Any CT not generically justified including patients who require intravenous contrast with a egfr <30, Pregnant and Paediatric patients REVIEW PROCESS: This document will be reviewed every 12 months It may be reviewed or amended at any time at the request of the Radiation Medical Practitioner ALBURY WODONGA HEALTH OTH0059 Page 3

GENERIC JUSTIFICATION PROTOCOLS Radiation Procedure: CT HEAD NOTES Clinical Question: Suspected intracranial pathology Space occupying lesion (SOL) Haemorrhage Clinical Indications: Acute onset severe headache Suspected cerebrovascular accident (CVA) Focal neurological signs Headache with fever Progressively worsening headache Post partum headache Headache different to usual migraine New onset headache in the setting of immunodeficiency or cancer Significant trauma Dementia screen Scan Protocol: kvp: 135 mas: AEC ALGORITHM: Brain 220mm CTDIvol: 46 DLP: 800 Effective Dose: 1.8mSv Supine with chin tucked down to reduce dose to the orbits Not unless specified by the Radiation Medical Practitioner Intravenous contrast will not be administered unless requested by the Radiation Medical Practitioner Axial / Coronal / Sagittal 5mm ALBURY WODONGA HEALTH OTH0059 Page 4

Radiation Procedure: CT SINUSES / FACIAL BONES NOTES Clinical Question: Suspected sinus pathology IV contrast may be given at the request of the Radiation Medical Practitioner in the setting of an abscess Clinical Indications: Polyps Surgical planning Trauma Neoplasm Inadequate response to medical therapy Scan Protocol: kvp: 100 mas: AEC ALGORITHM: Bone sharp 220mm CTDIvol: 46 DLP: 800 Effective Dose: 1.8mSv Supine in head rest Not usually Axial / Coronal / Sagittal 3mm ALBURY WODONGA HEALTH OTH0059 Page 5

Radiation Procedure: CT SOFT TISSUE NECK NOTES Clinical Question: Infection Trauma Thyroid Mass Tumour Staging Clinical Indications: Infection Mass Foreign Body Scan Protocol: kvp: 120 mas: Determined by AEC ALGORITHM: Soft / Bone 280mm CTDIvol: 18 DLP: 515 Effective Dose: 2.8mSv Supine in head rest Yes, if not contraindicated Axial / Coronal / Sagittal 5mm Dr John Louw ALBURY WODONGA HEALTH OTH0059 Page 6

Radiation Procedure: CT CERVICAL SPINE NOTES Clinical Question: Fracture Dislocation Bone lesion Clinical Indications: Cervical Spine Injury Spinal stenosis Trauma pt >65 yrs OR significant mechanism of injury OR already having CT Brain Normal cervical spine xrays with ongoing suspicion of spine injury Scan Protocol: kvp: 120 mas: AEC ALGORITHM: Soft / bone 280mm CTDIvol: 18 DLP: 515 Effective Dose: 2.8mSv Supine in head rest (non trauma) Supine on CT couch if in a collar Plain radiography should be considered prior to CT in the setting of non traumatic neck MRI is preferred method of imaging for radiculopathy No Axial / Coronal / Sagittal 3mm ALBURY WODONGA HEALTH OTH0059 Page 7

Radiation Procedure: CT LUMBAR SPINE NOTES Clinical Question: Fracture Bone lesion Trauma Spinal canal stenosis Disc herniation Tumour Clinical Indications: Low back pain with radiculopathy Cauda Equina Symptoms Pain with Red Flags Pain not improving following conservative management High energy mechanism of injury with pain Scan Protocol: kvp: 120 mas: AEC ALGORHYTHM: Thoraco / Lumbar Spine / Bone 250mm CTDIvol: 19 DLP: 674 Effective Dose: 10mSv Supine MRI is most appropriate in back pain imaging No Axial / Coronal / Sagittal Dr. Joun Louw ALBURY WODONGA HEALTH OTH0059 Page 8

Radiation Procedure: CT EXTREMITIES NOTES Clinical Question: Fracture Bone Mass Infection Clinical Indications: Fracture Osteitis Bone tumour Joint Pathology Scan Protocol: kvp: 120 mas: AEC ALGORHYTHM: Bone sharp / soft tissue sharp 200mm CTDIvol: N/A DLP: N/A Effective Dose: N/A Dependant on area to be scanned No Axial / Coronal / Sagittal 3mm ALBURY WODONGA HEALTH OTH0059 Page 9

Radiation Procedure: CT CHEST NOTES Clinical Question: Dyspnoea Mass Metastases Infection Clinical Indications: Abscess Haemoptysis with high risk for malignancy Tumour Scan Protocol: kvp: 120 mas: AEC ALGORHYTHM: Body Standard / Lung Standard 400mm CTDIvol: 5 DLP: 275 Effective Dose: 4.7mSv Supine feet first Yes unless contraindicated Axial / Coronal / Sagittal 5mm ALBURY WODONGA HEALTH OTH0059 Page 10

Radiation Procedure: CT CHEST (HIGH RESOLUTION) NOTES Clinical Question: Interstitial lung disease Clinical Indications: Bronchiectasis Silica Asbestos exposure Emphysema Chronic shortness of breath Scan Protocol: kvp: 120 mas: AEC ALGORHYTHM: Body Standard / Lung Standard 400 mm CTDIvol: 5 DLP: 275 Effective Dose: 4.7mSv Supine feet first No Axial / Coronal / Sagittal 5mm 1/10mm reformats Lung Sharp ALBURY WODONGA HEALTH OTH0059 Page 11

Radiation Procedure: CT CORONARY ANGIOGRAM NOTES Clinical Question: Coronary Artery Disease (CAD) Prospectively gated scans utilised where possible Clinical Indications: Patient has stable symptoms consistent with CAD and is low / intermediate risk of CAD Coronary artery anomaly or fistula Patient is undergoing non coronary cardiac surgery Scan Protocol: kvp: 100-120 mas: AEC ALGORHYTHM: Cardiac CTA 220mm CTDIvol: 35 DLP: 500 Effective Dose: 7mSv Supine feet first Modulated Retrospectively gated scans utilised where there are fluctuations in heart rate Yes Axial / Coronal / Sagittal 5mm ALBURY WODONGA HEALTH OTH0059 Page 12

Radiation Procedure: CT ABDOMEN (WITH IV CONTRAST) NOTES Clinical Question: Tumour Perforation Bleed Abcess Collection Bowel Obstruction Appendicitis Ischaemia Bowel pathology Diverticulitis Clinical Indications: Tumour diagnosis / staging Post operative complications Abdominal pain with raised inflammatory markers Abdominal pain with fever Severe weight loss Scan Protocol: kvp: 100-120 mas: AEC ALGORHYTHM: Standard Body 400mm CTDIvol: 8 DLP: 378 Effective Dose: 5.7mSv Supine feet first In most cases unless contraindicated or not tolerated Axial / Coronal / Sagittal 7mm ALBURY WODONGA HEALTH OTH0059 Page 13

Radiation Procedure: CT ABDOMEN (NON CONTRAST) NOTES Clinical Question: Renal calcluli Low dose protocol should be calculi utlilised for follow up patients or when specifically requested by Urologist Clinical Indications: Haematuria Severe loin / flank pain Scan Protocol: kvp: 100-120 mas: AEC ALGORHYTHM: Standard Body 400mm CTDIvol: 8 DLP: 378 Effective Dose: 5.7mSv Supine feet first No Axial / Coronal / Sagittal 5mm ALBURY WODONGA HEALTH OTH0059 Page 14

Radiation Procedure: Clinical Question: Staging CT NECK / CHEST / ABDOMEN / PELVIS +/- BRAIN (ONCOLOGY ONLY) NOTES Clinical Indications: Preliminary diagnosis Staging Scan Protocol: kvp: 100-120 mas: AEC ALGORHYTHM: Standard Body / Standard Lung 400mm CTDIvol: 16 DLP: 851 Effective Dose: 12mSv Supine feet first Yes unless contraindicated Axial / Coronal / Sagittal 7mm ALBURY WODONGA HEALTH OTH0059 Page 15

Radiation Procedure: CT PULMONARY ANGIOGRAM NOTES Clinical Question: Pulmonary Embolism (PE) Clinical Indications: Shortness of breath High risk of PE History of DVT with chest pain Scan Protocol: kvp: 120 mas: AEC ALGORHYTHM: Body Standard / Lung Standard 400 mm CTDIvol: 5 DLP: 275 Effective Dose: 4.7mSv Supine Feet first Yes Axial / Coronal / Sagittal 5mmm ALBURY WODONGA HEALTH OTH0059 Page 16

Radiation Procedure: CT COLONOGRAPHY NOTES Clinical Question: Tumour Polyp Clinical Indications: Failed Colonoscopy Colonoscopy contraindicated Referred only by Specialist Physician with a failed colonoscopy within 12 weeks prior Scan Protocol: kvp: 120 mas: AEC ALGORHYTHM: Standard Lung / Standard Body 400mm CTDIvol: 15 DLP: 850 Effective Dose: 12mSv Supine feet first and then Prone No Axial / Coronal / Sagittal 5mm ALBURY WODONGA HEALTH OTH0059 Page 17

AREAS REQUIRING JUSTIFICATION ON AN INDIVIDUAL BASIS (ALL PAEDIATRIC AND PREGNANT PATIENTS MUST HAVE THEIR CT IMAGING JUSTIFIED ON AN INDIVIDUAL BASIS) CT EXAMINATION REASON FOR JUSTIFICATION ON INDIVIDUAL BASIS CT Renal (multiphase) The number of phases may be reduced by the Radiation Medical Practitioner based on the non contrast image CT Liver (multiphase) The number of phases and extent may be adjusted by the Radiation Medical Practitioner based on the pathology and prior imaging CT Pancreas (multiphase) The number of phases and extent may be adjusted by the Radiation Medical Practitioner based on the pathology and prior imaging CT Angiogram (any area excluding CT Pulmonary Angiogram and CT Coronary Angiogram) All angiograms should be assessed by the Radiation Medical Practitioner on an individual basis to adjust. For example a cerebral angiogram may not be justified, but requested. Conversely it may be relevant to extend the angiogram when it is not specifically requested CT Thoracic Spine CT Thoracic spines will often be replaced with xrays based on clinical notes OR if justified, a limited scan with the area defined by the Radiation Medical Practitioner may be performed if appropriate ANY CT NOT GENERICALLY JUSTIFIED INCLUDING PATIENTS WHO REQUIRE INTRAVENOUS CONTRAST WITH A EGFR <30, PREGNANT AND PAEDIATRIC PATIENTS ALBURY WODONGA HEALTH OTH0059 Page 18

Annexes: Related AWH Documents: Accreditation Standards: Other Relevant References: Contact Point: Medical Imaging. In consultation with: TITLE / POSITION THIS SECTION FOR CORPORATE RECORDS OFFICE USE ONLY Approved by Executive / Delegate: Date Approved: SharePoint Location: Director of Corporate Support 22 February 2017 Other Responsible Department: Date for Review: Linked Documents: Medical Imaging 22 February 2020 Version No: Original Approval Date: Previously Named As: 2 22 August 2014 Same ALBURY WODONGA HEALTH OTH0059 Page 19