Reducing the Risk

Radiation exposure from medical imaging is an area of great concern to healthcare facilities in the wake of adverse incidents in 2010 at Cedars-Sinai Medical Center in Los Angeles, several other hospitals in California and at Huntsville Hospital in Alabama. Patients undergoing computed tomography (CT) brain perfusion scans at these facilities received radiation overdoses that led to hair loss, headaches, memory loss, confusion, burns and increased risks of cancer and brain damage.

These unfortunate incidents bring up wider-ranging questions: How much radiation does the average patient receive over a lifetime? What are the risks of this accumulation? And what can be done to monitor and reduce these doses?

According to Walt Bogdanich in his 2010 New York Times series on the serious health risks of radiation overdoses, “the average lifetime dose of diagnostic radiation has increased sevenfold since 1980, and more than half of all cancer patients receive radiation therapy.” Although radiation is lifesaving, understanding its risks and the complex technology used to deliver it is becoming ever more essential for healthcare providers.

Medical societies and different regulatory agencies, including the Food and Drug Administration, have reacted by investigating these incidents and publishing recommendations for monitoring and reducing radiation doses. CT is the imaging modality of primary concern, but radiation exposure during interventional radiology, cardiac catheterization and nuclear medicine procedures are also part of the focus.

HealthTrust’s Response

The HealthTrust Radiology Advisory Board evaluated original equipment manufacturers (OEM) and third-party image processing vendors with systems that can reduce doses. HealthTrust already had some products for dose reduction and monitoring available through its medical imaging contract portfolio.

HealthTrust has stayed on top of the latest research on CT dose reduction software, and recently published a paper on “Dose Reduction and Dose Monitoring Features and Upgrades for CT Scanners and Angiography Systems.” The report finds that the single most cost-effective means to control CT dose is to monitor and track CT doses. It recommends that “hospitals consider the options currently available, in the form of OEM open-source and third-party commercial products.”

The report found 50 percent dose reduction is possible with OEM processing technologies, but these technologies can cost from $150,000 to $200,000. The report recommends supply chain providers consider a third-party image processing system, with almost as effective dose savings (40 percent) and at a much lower cost of $50,000. While the OEM advanced-processing technologies are designed to work only on select models, the third-party system can be used on the majority of CT scanners.

ROI on CT Dose Reduction Software?

In evaluating vendors, HealthTrust is looking for evidence of an increase in tube life from the reduction in dose. Responses from OEMs have varied from “reduced dose does not extend tube life as most tube failures are from bearings” to reduced CT dose “will extend tube life by an estimated 20 percent.” One of the third-party image system vendors responded with a white paper reporting that “owners of CT systems observed that using low-dose protocols significantly increased the number of scans, anywhere from 40 percent to as much as a factor of 4, well beyond the expected values of the manufacturers.”

Annual CT service contracts can average as much as $165,000 per year—with the tube being the majority of that cost—but this technology can provide a significant clinical benefit to patients by reducing dose. If the service contract is renegotiated, the ROI would be very short, especially for third-party image system products that can be used on the majority of CT scanners (instead of select CT models as is the case with some OEMs).

Potential Issues with Patient Throughput

Both OEMs and third-party image system software could have an effect on patient throughput. Most post-processing at a reduced dose will have minimal impact on patient throughput, adding only one to five minutes per case. However, some products could take approximately 15 minutes just to improve the image quality of a low-dose image, which greatly extends the average time needed to complete a multi-slice CT exam.

The Joint Commission’s Recommended Action

In August 2011, The Joint Commission released a Sentinel Event Alert related to radiation exposure and specific actions that hospitals and imaging centers should take. The specific actions suggested by The Joint Commission include:

• Use of imaging techniques other than CT, such as ultrasound or magnetic resonance imaging (MRI), and collaboration between radiologists and referring physicians about the appropriate use of diagnostic imaging.
• Adherence to the Nuclear Regulatory Commission’s “As Low as Reasonably Achievable” (ALARA) guidelines, as well as guidelines from the Society for Pediatric Radiology, American College of Radiology and the Radiological Society of North America for imaging for children and adults, respectively.
• Assurance by radiologists that the proper dosing protocol is in place for the patient being treated and reviews of all dosing protocols against the latest evidence are made either annually or every two years.
• Expansion of the radiation safety officer’s role to explicitly include patient safety as it relates to radiation and dosing, as well as education on proper dosing and equipment usage for all physicians and technologists who prescribe diagnostic radiation or use diagnostic radiation equipment.
  Implementation of centralized quality and safety performance monitoring of all diagnostic imaging equipment that may emit high amounts of radiation cumulatively.

Radiation exposure will continue to be a patient safety issue. Medical imaging vendors are improving both devices and software to reduce and monitor patient dose during diagnostic and therapeutic procedures. However, it is ultimately the responsibility of the clinical staff, both physician and technologist, to follow and adhere to all guidelines to reduce and monitor radiation dose from medical imaging procedures.

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