The Image Gently campaign: Possible to do more with less?

Transkript

1 The Image Gently campaign: Possible to do more with less? Marilyn J. Goske MD, FAAP Chair, The Alliance for Radiation Safety in Pediatric Imaging Corning Benton Endowed Chair in Radiology Education Professor of Radiology and Pediatrics Cincinnati Children s Hospital Medical Center Cincinnati, Ohio

2 ACKNOWLEDGEMENTS

3 Founding societies Society for Pediatric Radiology American College of Radiology American Society of Radiologic Technologists American Association of Physicists in Medicine

4 Acknowledge Steering committee Marilyn J. Goske MD, Chair Kimberly E. Applegate MD, MS Jennifer Boylan, MA Dorothy Bulas, MD Priscilla F. Butler, MS Michael J. Callahan MD Brian D. Coley, MD Steven Don, MD Shawn Farley Donald P. Frush MD Marta Hernanz-Schulman MD Susan D. John MD Sue C. Kaste DO Sarah Kaupp, parent advocate Ceela McElveny Gregory Morrison, CAE, MA RT(R), CNMT Manrita Sidhu, MD Keith J. Strauss MS Ted Treves MD Coreen Bell, administration

5 DISCLOSURES

6 Disclosures #1 No financial disclosures

7 Disclosures #2 I had a really, really hard time developing this talk.

8 ANALYSIS OF QUALITY IS SO COMPLEX

9 Image Gently Report Card

10 Factors to analyze in radiation safety: How has Image Gently/ pediatric community performed? Patient safety: awareness, education, advocacy Image quality (ACR Pediatric Dose Index Registry) Clinical outcomes (impact)

11 Quantifying Radiation Safety and Quality in Medical Imaging Provide guidance to consumers Develop community-wide radiation standards and best practice Develop new applications to pro-actively minimize radiation dose Reiner BI. JAmCollRadiol 2009;6:558

12 What is Image Gently? Education, awareness, advocacy campaign Goal: To promote radiation protection for children worldwide Grassroots campaign uses social marketing to effect change locally

13 What is the Image Gently campaign? Founded in 2007 Alliance for Radiation Safety in Pediatric Imaging >72 health care organizations/agencies >800,000 radiologists radiology technologists medical physicists worldwide

14 Social marketing 1. Media interventions 2. Public education 3. Social marketing Target audience 1. Public/parents 2. Health professionals 3. Manufacturers (MITA) 4. Government (FDA) 5. Agencies (IAEA, WHO and others) Media 1. Print 2. Internet 3. Radio 4. Television 5. Posters Social media

15 Raising awareness Website 5 campaigns Speakers group Scientific publications Image Gently summits Speakers at national meetings Parent brochures Newsletter Facebook Twitter Power of the ALLIANCE

16 FACT: Pediatric radiopharmaceutical dose varied up to 20 times for patients of the same size, same exam Treves ST, Davis RT, Fahey FH.JNuclMed49:

17 Medical experts wanted to do something about this Pediatric NM Pediatric Dose Consensus Workshop SPR, Boston 2010

18 Approved By SNMMI, ACR, SPR

19 How many read the article and changed their practice?

20 17 years

21 Journals, Trade Press, Alliance partners, websites JNM, JNM Tech, Pediatric Radiology, AJR, jacr (AJR), ACR Bulletin, ASRT Scanner, Radiology, Health Physics, Clinical Nuclear Medicine, Radiology today, RT Image, SCORCH, Aunt Minnie, Health Imaging, Diagnostic Imaging, Journal in Pediatrics, Imaging Economics, Radiology Business Journal

22 Image Gently Go with the Guidelines campaign ad and guidelines poster Photographers: Dr Mike Callahan, daughter Nora, Dr Ted Treves Design ASRT Collaborator: Society of Nuclear Medicine

23 Raising awareness: A+

24 Factors to analyze in radiation safety: How has Image Gently/ pediatric radiology community performed? Patient safety: awareness, education, advocacy Image quality (ACR Pediatric Dose Index Registry) Clinical outcomes (impact)

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26 ACR CT accreditation- pediatric component

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28 Interventional Radiology Rollout August, 2009 FREE safety checklist FREE powerpoint talk FREE parent pamphlet

29 The image part with relationship ID rid9 was not found in the file.

30 8 FREE online modules for CT technologists Toshiba, GE, Philips, Siemens Design courtesy of ASRT

31 IG Parent Campaign Rollout January, 2009 Free parent brochures Free medical imaging record card

32 Schonende Bildgebung Anleitung zur Entwicklung von pädiatrischen CT-Protokollen Einleitung: Vor dem Jahr 2001 wurde die überwiegende Mehrzahl von CT-Untersuchungen bei Kindern mit denselben oder ähnlichen Protokollen durchgeführt wie CT- Untersuchungen bei Erwachsenen. Im Jahr 2001 erschienen mehrere wissenschaftliche Artikel (1-3), in denen darauf hingewiesen wurde, dass dieses Vorgehen ungeeignet sei und dies bei unseren kleinsten Kindern zu einer bis zu drei mal höheren Dosisbelastung führt als bei Erwachsenen. Seitdem wurden in der wissenschaftlichen Literatur zahlreiche wissenschaftliche Arbeiten, die sich mit Protokollen zur Dosisreduktion bei pädiatrischen CT-Untersuchungen beschäftigen, publiziert (4-17). Viele dieser Protokolle sind jedoch spezifisch für bestimmte CT- Gerätetypen und nicht auf andere CT-Geräte übertragbar. Derartige Anleitungen geben entweder Unterstützung in der Entwicklung von pädiatrischen Protokollen oder erlauben es, die geltenden Protokolle zu vergleichen bzw. ihre Eignung sicher zu stellen. Das gegenständliche Dokument ist ausschließlich als eine Anleitung zu sehen. Die technischen Parameter haben lediglich Empfehlungscharakter für die Umsetzung der CT- Untersuchungstechnik. Der verantwortliche Radiologe/die verantwortliche Radiologin in Abstimmung mit einem Medizinphysiker/einer Medizinphysikerin muss alle Änderungen der CT Untersuchungstechnik, die zu einer Reduktion der Strahlenbelastung führen dahingehend evaluieren, dass sicher gestellt wird, dass die diagnostische Information adäquat ist. Es wurden CT-Geräteparameter mit dem Ziele einer Dosisreduktion aufbauend auf Dosismessungen mit Ionisationskammern und anatomischen pädiatrischen CT- Phantomen (18) entwickelt. Die Phantomgröße reicht von der Kleinkindergröße bis zum Erwachsenen, sie bestehen aus einem Gewebe äquivalenten Kunststoff mit einer Dichte von null HU. Die abdominellen Phantome haben eine gewebeäquivalente Wirbelsäule; die Thoraxphantome haben ebenfalls eine gewebeäquivalente Wirbelsäule und gewebeäquivalentes Lungengewebe; die Schädelphantome verfügen über gewebeäquivalenten Schädelknochen. Um diese Reduktionsfaktoren sinnvoll nutzen zu können, sollte der Radiologe/die Radiologin zu anfangs mit radiologisch-technischem CT-Personal zusammenarbeiten, um sich mit den CT-Techniken bei Kindern und Erwachsenen vertraut zu machen. Als erster Schritt muss verifziert werden, dass die Erwachsenen- CT-Untersuchungstechnik bzw. die entsprechende Strahlenbelastung nicht größer ist als die durch das American College of Radiology (ACR) CT- Akkreditierungsprogramm empfohlenen Dosiswerte (19, 20). Es gibt keine universelle CT-Technik, die für die CT-Geräte aller CT-Anbieter bei Erwachsenen angewendet werden kann. Unterschiede im Design verschiedener CT-Geräte (z.b.körperformfilter, Brennfleck-Detektorabstand, Detektorempfindlichkeit bzw. Effizienz etc.) verunmöglichen es, die auf den Patienten wirkende Strahlendosis auf Basis der Geräteparameter abzuschätzen. Konsequenterweise muss ein qualifizierter Medizinphysiker (21, 22), der entsprechende Ausbildungsnachweise aufweisen kann zur Verfügung stehen, der den Dosisoutput des jeweiligen CT-Gerätes messen kann, um die Dosis zu berechnen und damit geeignete abdominelle CT-Techniken und Schädel-CT-Techniken entwickeln zu können. Jeder qualifizierte Medizinphysiker, فحص الا شعة برفق Image Gently Pledge تعهد والتزام ا رغب ا ن اجري فحص الا شعة برفق Yes, I want to image gently. ا جل انطلاقا من معرفتي ا ن كل فرد في فريق الرعاية الطبية يلعب دورا حيويا برعاية المريض ويطمح داي ما لتقديم ا فضل رعاية له فا ننى ا تعهد: Recognizing that every member of the healthcare team plays a vital role in caring for the patient and wants to provide the best care, I pledge: ا ن ت كون رسالتنا ل " فحص الا شعة برفق" على را س ا ولوياتنا عند تحادث وتواصل ا عضاء فريقنا الطبي في هذا العام. to make the image gently message a priority in staff communications this year ا ن نقوم باستعراض التوصيات (ا و البروتوكولات المقترحة) وا ذا استدعت الضرورة فسوف نقوم بتعديل اجراءاتنا لتتوافق مع هذه التوصيات المقترحة من قبل الحملة. to review the protocol recommendations and, where necessary, implement adjustments to our processes ا ن نحترم ونستمع ا لي الاقتراحات المقدمة من كل فرد من ا عضاء فريق الفحص بالا شعة حول سبل ضمان ا جراء التعديلات المنشودة. to respect and listen to suggestions from every member of the imaging team on ways to ensure changes are made ا ن نتواصل مع ا ولياء الا مور بشفافية. to communicate openly with parents لكم جزيل الشكر علي التزامكم بالهدف المنشود من حملة " فحص الا شعة برفق " عند ا جراء فحص الا شعة للا طفال ا و علاجهم. Thank you for committing to the goal to image gently when you image or treat children. فلنبادر بنشر هذا الهدف الطيب في القسم الذى تعملون به او في مجال تخصصكم ا و في المستشفي ا و العيادة التى تعملون بها Spread the word in your department, practice, hospital or clinic. First Name * Last Name * الا سم الا ول اسم العاي لة (الكنية) - -

33 Practice Quality Improvement Project for radiologists: Review 25 pediatric patients in their practice 10 quality metrics FREE at Imagegently.org SPR R and E Foundation

34 Susan John, MD Chair of CR/DR Education committee

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36 Online PQI project and worksheet Funded by FDA contract

37 Providing educational materials: B+ B+

38 Work needed: Know your equipment Ultrasound educational materials /campaign Need to allign: clinical guidelines (AAP, other groups) imaging guidelines (ACR) Image Gently imaging protocols

39 Factors to analyze in radiation safety: How has Image Gently/ pediatric community performed? Patient safety: awareness, education, advocacy Image quality (ACR Pediatric Dose Index Registry) Clinical outcomes (impact)

40 Put kids imaging in the spotlight

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43 WE HAVE NOT BEEN ABLE TO EASILY MEASURE THE RADIATION DOSE OUR PATIENTS RECEIVE!

44 Successful in advocating to AAPM to develop Size Specific Dose Estimate The determination of ionizing radiation dose to a living human from an x-ray exam is very complex.. JACR 2007 May 4(5) 272

45 Task Group 204 A single, simple method to estimate actual patient dose within 10-20%! An intermediate step until actual organ doses can be calculated HUGE advance for patients John Boone PhD, Co-Chair Keith Strauss MS, Co-Chair

46 Advocated for single exposure index in digital radiography AAPM (Dr. Tony Seibert, past President) and IEC Now one standard!

47 Advocacy: B+ B+

48 Factors to analyze in radiation safety: How has Image Gently/ pediatric community performed? Patient safety: awareness, education, advocacy Image quality (ACR Dose Index Registry Pediatric section) Clinical outcomes (impact)

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50 JHC - 21 actions Alternate imaging Use ACR appropriateness criteria CT accreditation Adhere to ALARA Adhere to Image Gently (children) Image Wisely (adult) guidelines Provide reference dose ranges Assure proper dosing protocol for patient Review protocols every 1-2 years Investigate patterns outside of ranges Record dose or exposure as part of report

51 Essentially NO DIAGNOSTIC REFERENCE RANGES FOR PEDIATRIC PATIENTS IN THE U.S.

52 In the United States We don t know what doses pediatric CT patients are receiving. - NEXT survey - ACR CT pediatric accreditation

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55 IAEA survey of pediatric CT practice in 40 countries in Asia, Europe, Latin America and Africa: Part 1. Frequency and Appropriateness Part II: Procedures & Protocols Part III: Impact of Actions Slide courtesy of Dr. Madan Rehani

56 TJC

57 A to the ACR for the National Radiology Data Registry ACR has created the Dose Index Registry MAJOR ACCOMPLISHMENT! Provides real-time CT dose data Rick Morin, Mythreyi Bhargavan, Laura Coombs

58 ACR National Radiology Data Registry (NRDR) Work supported by RSNA SCHOLAR GRANT, SPR Research and Education Foundation

59 Purpose of Quality Improvement Registry in CT Scans in Children: Determine estimate of pediatric patient dose for CT of the abdomen 6 children s hospitals (QuIRCC) Baseline scan technique/ dose index in children Establish DRLs using SSDE Use quality improvement methods Goal : to standardize/optimize practice using continuous cycles of improvement

60 Results n= 939 pediatric patients male = 499 (53%) female = 440 (47%) Number of patients in each age group n= 241 n= 17 n= 86 n= 399 n= 196 Newborns 1 yr 5 yr 10 yr > 15 yr

61 Results QuIRCC DRL is lower than UK DRL using CTDI w Normalized to 32 cm phantom 5 yr old abdomen CTDI vol = CTDI w pitch QuIRCC 3 rd quartile Shrimpton 3 rd quartile* 5 yr old (20-24 cm) 7.6 mgy 12.5 mgy 39% *Shrimpton PC, Wall BD (2000) Reference doses for paediatric computed tomography. Radiat Prot Dosim, 90, Presented International Paediatric Radiology meeting, June 2011

62 We included subjective image analysis Image A is > 2x Image B A. Higher technique/ dose B. Lower technique/ dose

63 Providing image quality criteria: C- C-

64 COLLABORATION Manufacturers/ MITA/FDA: New technologies lead to significant patient dose reduction Ongoing and accelerated communication!

65 Still need.. Pediatric patients lack DRL for: CR/DR, flouro head, neck CT Improved methods of estimating patient dose Better method of defining image quality Need practices to join ACR DIR Pediatric CT accreditation

66 Factors to analyze in radiation safety: How has Image Gently/ pediatric community performed? Patient safety: awareness, education, advocacy Image quality (ACR Dose Index Registry Pediatric section) Clinical outcomes (impact)

67 Survey Impact of IG n=183 respondents Non-children s based hospitals >90% did pediatric patients 95% name recognition for IG Self report of change of CT protocols to child-size versus actual implementation of change

68 5 grant attempts to measure ACTUAL impact ALL UNSUCCESSFUL!

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70 Image Gently Financial Snapshot Year Revenue Expenses * , , , , , , , , , (1 st Quarter) , Totals $157, $112, TOTAL REVENUE - EXPENSES $45, About 28K/yr, most spent on printed materials and.6fte One time education grant from GE Healthcare No other funding aside from founding societies

71 Factors to analyze in radiation safety: How has Image Gently/ pediatric radiology community performed? Patient safety: awareness, education, advocacy Image quality (ACR Pediatric Dose Index Registry) Clinical outcomes (impact)

72 What do you think?