Welcome to Image Gently: A Practice Quality Improvement (PQI)Program in Computed Tomography (CT) Scans in Children

What is practice quality improvement (PQI)?

In 1999, the Institute of Medicine published its pivotal report called “To Err is Human.” It highlighted the need for improved safety in medical care for patients and estimated that as many as 98,000 patients die each year from preventable medical error. This report challenged the medical profession to chart a course of self improvement. The American Board of Medical Subspecialties have created numerous initiatives to improve the quality of healthcare through diplomate initiated learning and quality improvement through a process called Maintenance of Certification (MOC).

MOC has four components:

• Part 1- Professional standing (Medical licensure as an example)
• Part 2- Evidence of life long learning and periodic self assessment (i.e. CME and SAMS courses)
• Part 3- Cognitive expertise in the form of subspecialty certification exams
• Part 4- Evaluation of performance in practice

This last component is the driver for the development of practice quality improvement projects in radiology.

What are the basic steps to perform a PQI project?

Practice quality improvement in radiology is a process of:

• selecting and analyzing an area of practice you wish to change or enhance
• divide the “change” into a manageable series of steps
• analyze each step

Data collection is a critical component of any meaningful PQI project. Ideally the project must allow for accurate data collection so that variation either within a practice or from practice to practice can be analyzed. Ideally data gathered from your project would be compared to national benchmarks for the process one is attempting to improve.

What are the reasons why PQI is good for my patients and practice?

As physicians we all want to provide the best care for our patients. By selecting specific areas of your practice to evaluate and improve, you ensure that your practice is continually re-examining itself to promote safety for your patients.

A practice quality improvement project should:

• be relevant to your practice
• be able to be performed in your practice with the resources available to you
• produce measurable results that can be repeatedly measured
• effect quality improvement for your patients

PQI Steps

• Plan               (what do I want to improve?)
• Do                 (collect data)
• Study             (what I found out)
• Act                 (make improvement)
• Repeat²  

To further improve CT safety for children over the next several years, the following is an example of review cycles that you may perform.

• Cycle 2 Repeat Cycle 1- Reassess
  Has my practice improved when compared to the original data I collected? 

• Cycle 3 Optimization of safety for Head CT in Children
  Now that I have optimized performance of CT scans of the abdomen in children, the next PQI project will address CT scans of the head performed in children

• Cycle 4 Repeat Cycle 3
  Has my practice improved when compared to the original data I collected on head CT? 

• Cycle 5 Optimization of safety for Chest CT in Children
  Now that I have optimized performance of CT scans of the abdomen and head in children, the next PQI project will address CT scans of the chest performed in children

• Cycle 6 
  Has my practice improved when compared to the original data I collected?   

References:  (References in blue font are linked to original article for further reading)
1. Strife JL, Gary LE, Becker J et al. The American Board of Radiology perspective on maintenance of certification: part IV--Practice quality improvement in diagnostic radiology.  AJR Am J Roentgenol. 2007 May;188(5):1183-6.

2. Applegate KE. Continuous Quality Improvement for Radiologists. Acad Radiol. 2004 Feb; 11(2): 155-161.

A metric is a standard of measurement.

A metric  may also be “ a system of related measures that facilitates the quantification of some particular characteristic” and provides a basis for comparison; a reference point against which other things can be evaluated;

[From Latin metricus, relating to measurement]

Reference: http://www.thefreedictionary.com/metric

Materials you will need to complete this PQI project:

• a list of 25 pediatric patients
• a PACS workstation. All data you need should be available through documentation in your PACS or other electronic medical record system.
• a computer with internet access and a printer.
• print the “METRIC WORKSHEET” This organizies the data you are collecting for the PQI project
• print the one page CT  PARENT QUESTIONNAIRE/ PROTOCOL SHEET.  This sheet will be referred to throughout this module. This worksheet may be downloaded and used as is or modified for your practice. Many of the metrics highlighted in this module may be assessed and documented using this simple tool.
• print the "PRACTICE IMPROVEMENT PLAN WORKSHEET"
• print a copy of your institutions body CT protocols
• open your web browser.

This free online PQI product does NOT STORE your individual practice data. Documentation of this PQI project requires you to either:

Print and save the paper forms with your answers when you have completed this project OR

Save the metric worksheet and practice improvement plan to your computer to document completion of this project.

1. Selecting your study population

Patients for your study population should be randomly selected. A staff member cleared to access confidential patient information should select the patient that fit the following profile and provide you with their medical record number:

• 5 CT scans (Abdomen/ Pelvis) performed in children 1-3 years,
• 10 CT scans (Abdomen/ Pelvis) performed in children 4-11 years,
• 10 CT scans (Abdomen/ Pelvis) > 12 years

2. Selecting your CT scans

This learning activity will ask you for baseline data from your current CT practice in 25 children whose scans were performed at your workplace and that you interpreted in the past 12 months using the following CPT codes:

• CT Abdomen with contrast                         CPT 74160
• CT Abdomen with and without contrast       CPT 74170
• CT Pelvis with contrast                              CPT 72193
• CT Pelvis with and without contrast            CPT 72194

Each CT of the abdomen and CT of the pelvis on the same patient should count as one scan.

Areas for assessment and potential improvement evaluated in this module include:

• communication from the ordering doctor that justifies performance of the CT scan
• communication between the radiologist and  pediatric patient and their parents/  caregiver about the CT exam and documentation in PACS .
• documentation of critical patient information  necessary prior to performance of the scan
• evaluation of strategies to decrease patient dose
• evaluation of radiation dose display

Metric 1 Justification for exam provided by referring physician

This metric evaluates the level of communication from the ordering physician to the radiologist. Providing information to radiologists about the medical reason for performance of the CT scan prior to the study is critical for the radiologist in obtaining the appropriate and optimal exam.

• The goal of this metric is 100% compliance at Level/score 2.
• In review of the 25 patients involved in this PQI project,

SCORE:

• 0 Minimal information was provided. This may include abbreviations such as “RLQ  pain “
• 1 Adequate information was provided but no specific information relative to the  patient. Patient has a chronic illness and this information was not provided
• 2 Information given indicated general health of patient, indication for study and  specific question to be answered by the study.                    

Metric 2 Parent/patient education provided by your institution/practice

This metric evaluates the communication from the radiologist to the parent/caregiver. Providing information to parents about the performance and risks of a CT scan prior to the study is a method to educate parents about the test and improve health literacy.

• The goal of this metric is 100% compliance at Level/ score 2.
• In review of the 25 patients involved in this PQI project,

SCORE: 

• 0 No parent information was provided
• 1 Parent had an opportunity to view departmental information about the CT scan  but this is not documented
• 2 Parents received departmental information about the CT scan. Documentation of  parents receiving CT informational materials  is archived and easily accessible by  the interpreting radiologist

Metric 3 Communication of critical patient information from parent to radiologist prior to scan

This metric explores the communication from the parent/caregiver to the radiologist interpreting the scan. Parents may be excellent sources of medical information for the radiologist as to why a test is being performed on their child. Review the patient information sheet given to each parent before a CT scan is performed in your practice

• The goal of this metric is 100% compliance at Level/score 2.
• In review of the 25 patients in your study population,

SCORE: 

• 0 No parent to radiologist information was provided
• 1 Parent to radiologist information was collected but not archived
• 2 Parent to radiologist information was archived and easily accessible by the  interpreting radiologist

Metric 4 Documentation of LMP/ pregnancy test status prior to performance of CT scan

This metric evaluates the practice of screening for pregnancy in females 12 years of age and older. Radiation protection to the fetus is a core concept of the ALARA principle.

• The goal of this metric is 100% compliance at Level/ score 2.

SCORE:

• 0 LMP or recent HCG is not documented
• 1 LMP is documented but there are no initials of person making inquiry
• 2 LMP/HCG is documented, initialed by technologist and archived and easily accessible by the interpreting radiologist
  N/A  Not applicable (male, pre-menarche female)

Metric 5 Documentation of history of renal disease and/ or renal function

This metric explores the radiologist’s knowledge of the patient’s renal function, either by inquiry into past history of renal disease or knowledge of the patient’s creatinine. Children’s creatinine level varies with age. A normal adult creatinine level in an infant is abnormal. While the incidence of contrast induced nephropathy is less common in children than adults, it remains one of the more common causes of acute renal failure in children.

• The goal of this metric is 100% compliance at Level/ score 3.

SCORE: 

• 0 No documentation of renal history and/ or renal function
• 1 Laboratory tests available in electronic medical record but not easily accessible by the interpreting radiologist
• 2 Renal history documented and/or laboratory values archived and easily  accessible by the interpreting radiologist
• 3 Renal history documented, laboratory values archived, reviewed by radiologist, and acted upon appropriately  ( Example: no significant history of renal disease documented, reviewed by radiologist, proceed with scan or elevated creatinine noted, nephrologist contacted and communication documented in patient radiology report)

Metric 6 Documentation of allergy history prior to administration of intravenous contrast

This metric evaluates the past history of the patient for contrast allergy, asthma or other allergies or conditions that may predispose the patient to an allergic reaction from intravenous iodinated contrast. While the incidence of anaphylaxis from contrast is rare in children, it remains a potentially life-threatening concern.

• The goal of this metric is 100% compliance at Level/ score 3.

SCORE:

• 0 No documentation of allergy history  
• 1 An inquiry into allergy history was made but not archived and the results are not easily accessible by the interpreting radiologist
• 2 Inquiry into allergy history was made, archived and easily accessible by the interpreting radiologist
• 3 Allergy history documented, archived, reviewed and acted on appropriately by radiologist (Example: allergy history reviewed, no significant allergy history, proceed with scan or child with prior severe reaction, radiologist contacts referring doctor and determines appropriate action. Communication documented in patient record.)

Metric 7   Use of breast shields in girls/women

This metric explores the use of shielding or technique modulation to reduce radiation dose to girls and young women. The most appropriate approach to reduce the radiation dose to breast tissue during CT scans may vary with the manufacturer of the CT unit. Consult with your manufacturer and medical physicist for guidance.

• The goal of this metric is 100% compliance at Level/ score 2.

SCORE:

• 0  Breast shields or technique modulation procedures are not available
• 1  Breast shields or technique modulation were not used
• 2  Breast shields or technique modulation were used
• N/A  Not applicable              

Metric 8 Single phase scans are adequate for most pediatric scan indications

This metric explores the number of scan phases. For most pediatric body CT scans, single phase scans are adequate.

• The goal of this metric is 100% compliance at Level/ score 2.

SCORE:

• 0 Non-contrast, immediate IV contrast and delayed scans were performed
• 1 Non-contrast and contrast scans were performed
• 2 Single scan was performed (non-contrast or IV contrast)
• N/A  Serial scans were approprate in this patient

Metric 9 Radiation dose may be decreased by limiting scans to the portion of the body necessary to answer the medical question

This metric reviews the scan length/body part ordered relative to the ordering doctor’s clinical history.

• The goal of this metric is 100% compliance at Level/ score 2.

SCORE: 

• 0 One or more scan areas were obtained without clear cut indication (Example: upper abdominal pain. Patient received pelvis and/ or chest CT)
• 1 Indicated scan areas performed, but longer scan length was used  (Example: breast, mid lung included in abdominal CT)
• 2 Scans performed correlated with indication and only indicated areas  included in the scan

Metric 10  Radiation dose to patients may vary widely for the same CT examination on patients of similar size/age due to the use of varying technique, in particular mAs

This metric reviews the consistency with which your practice follows your own  protocols for patients of similar size/ age.

• The goal of this metric is 100% compliance at Level/ score 2.

SCORE:

• 0 Our practice does not vary technique with the size/age of patient
• 1 Our practice has technique charts or automated exposure control, but neither was used for this patient
• 2 Automated exposure control was used for this patient or the age/ size-based technique chart at our institution was followed for this patient

Learning exercise 11

• What does the dose capture displayed on PACS represent?
• Does CTDI_vol give a display of individual patient dose?

CTDI_vol is an ESTIMATE or index of radiation dose.
This learning excercise explores the radiologist understanding/use of CTDI_vol in their practice.  CTDI_vol does not represent individual patient dose but is a useful metric typically displayed on CT scanners. This value is currently based on using a 32 cm diameter adult body phantom or a 16 cm adult head phantom and gives the dose the adult PHANTOM would have received on a specific scanner with the technical factors used.  The size of the pediatric patient relative to the adult phantom determines the size of the error between the pediatric patient’s radiation dose and the dose to the adult phantom that is displayed by the CT scanner.  The smaller the child, the greater the error in the dose display.

• List the CTDI_vol and phantom sized used (16 or 32cm) for the 25 patients in your study population and the age of the patient on the worksheet.

SCORE:  N/A

Learning tools and practice interventions to improve my practice

This section of your PQI project provides scientific references and ACR guidelines to improve your understanding of safety issues related to the performance of CT scans in children.

It also provides links to practice improvement tools that are free and readily available for you to download for your practice. You may modify these to suit your individual practice. You then have an opportunity to document in the space/ box provided, your practice improvement plan.

BASELINE DATA       Date CYCLE 1 __________________________________

Metric 1 Justification for exam provided by referring physician:

This metric evaluates the level of communication from the ordering physician to the radiologist. Providing information to radiologists about the medical reason for performance of the CT scan prior to the study is critical for the radiologist in obtaining the appropriate and optimal exam.

The goal of this metric is 100% compliance at Level/ score 2.

In review of the 25 patients involved in this PQI project,

SCORE:

0          Minimal information was provided. This may include abbreviations such as “RLQ                         pain “

1          Adequate information was provided but no specific information relative to the     patient. Patient has a chronic illness and this information was not provided

2          Information given indicated general health of patient, indication for study and      specific question to be answered by the study.

EVIDENCED BASED MEDICINE

The term “justification” comes from the word “justify” defined as “to be proven or shown to be just, right, or reasonable”^1. The National Council on Radiation Protection and Measurement further defines “justification” as “the part of the decision making process in which the options that are expected to do more good than harm are identified” ². (Link to PDF.NCRP Composite Glossary). This concept emphasizes the need for justification of all medical imaging that use ionizing radiation. Justification of the exam is a joint responsibility of the referring physician who has seen and examined the patient and the radiologist who reviews the request and indications and determines the appropriateness of the exam. The American College of Radiology’s guidelines on communication (Link PDF ACR guidelines.communication) discuss the 3 levels of patient information provided to the radiologist. Optimal patient information not only provides the radiologist with the signs/ symptoms in the patient but gives pertinent past medical history and provides the specific question to be answered by the imaging exam. Particularly in children and young adults, the ALARA principle, As Low As Reasonably Achievable should be followed. In the expert opinion of the radiologist and in conjunction with the referring physician, another study may be substituted that does not use ionizing radiation and this study maybe preferable in certain circumstances. Communication between referring physician and radiologist is most important.³

^1. Merriam-Webster on line dictionary. Access verified January 19, 2009. http://www.merriam-webster.com/dictionary/justified

². National Council on Radiation Protection and Measurement. http://www.ncrppnline.org/PDF/NCRP%20Composite%20Glossary.pdf.

Access verified January 22, 2009.

³. Krug SE. The art of communication: strategies to improve efficiency, quality of care and patient safety in the emergency department setting. Pediatr Radiol 2008:38 Sup4:S655-9

PRACTICE IMPROVEMENT TOOL: The American College of Radiology’s Practice Guideline on Communication of Diagnostic Imaging Findings (http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines/dx/comm_diag_rad.aspx) discusses the imperative for optimizing patient information to the referring radiologist. It states” Communication of information is only as effective as the system that conveys the information. A request for imaging should include relevant information, a working diagnosis, and/ or pertinent clinical signs and symptoms. In addition, including a specific question to be answered can be helpful. Such information helps tailor the most appropriate imaging study to the clinical scenario, enhances the clinical relevance of the report and thus promotes optimal patient care.”  In your practice improvement plan you may wish to review the mechanism/ steps involved by which you receive information from the referring physician. Inquiries as to methods to improve the information system or interventions to promote referring physicians providing more information may be performed.

PRACTICE IMPROVEMENT PLAN (Write your practice improvement  plan in the box below. For example, I will give a lecture to pediatric residents that discusses appropriate indications for abdominal pain and include examples where better communication improved patient care or I will review/ update the radiology information system to allow for improved patient information to be provided to the radiologist by the ordering physician.)

Metric 2 Parent/patient education provided by your institution/practice:

This metric evaluates the communication from the radiologist to the parent/caregiver. Providing information to parents about the performance and risks of a CT scan prior to the study is a method to educate parents about the test and improve health literacy.

The goal of this metric is 100% compliance at Level/ score 2.

In review of the 25 patients involved in this PQI project,

SCORE:

 0         No parent information was provided

 1         Parent had an opportunity to view departmental information about the CT scan    but this is not documented

 2         Parents received departmental information about the CT scan. Reception of CT   informational materials by parents is archived and easily accessible by the      interpreting radiologist

EVIDENCE BASED MEDICINE:

In 2007, Larson et al performed a survey of 100 parents that assessed parents understanding of CT scans for their child. Before the handout was given, only 66% believed that CT scans involved radiation. After the handout was given, 99% understood that radiation was involved in performance of the scan. No parent or caregiver refused a CT scan after the information was given.

Larson DB, Rader SB, Forman HP et al. Informing parents about CT Radiation Exposure in Children: It’s OK to Tell Them. AJR 2007;189;271-275 LINK PDFLarson

Practice Improvement Tool: The Image Gently website has 3 information pamphlets you may download for free and use for your practice.

For parents: 2 page brochure about CT scans in children LINK PDF 2 page

For parents: 8 page handout about use of radiation for all types of imaging in children LINK PDF 8 pg

For parents: Larson et al: Parent Handout LINK AJR Larson

Practice Improvement Plan: (List education interventions for parents. For example, “I will download the 2 page brochure and give to all parents and document that information was given on the Parent Information Questionnaire.”)

Metric 3 Communication of critical patient information from parent to radiologist prior to scan.

This metric explores the communication from the parent/caregiver to the radiologist interpreting the scan. Parents may be excellent sources of information for the radiologist as to why a test is being performed on their child. Review the patient information sheet given to each parent before a CT scan is performed in your practice

The goal of this metric is 100% compliance at Level/ score 2.

In review of the 25 patients in your study population,

SCORE: 

0          No parent to radiologist information sheet was provided

1          Parent to radiologist information was collected but not archived

2          Parent to radiologist information was archived and easily accessible by the         interpreting radiologist

EVIDENCE BASED MEDICINE: There are few scientific studies on the impact of patient information provided to the doctor, particularly in radiology at the time of CT scan. Communication with patients is most important in identifying patient’s complaints and concerns when they present for imaging. Fifty-four percent of patients’ complaints and 45% of their concerns are not elicited at the time of a physician-patient encounter in the primary care setting.¹ Streeter and Makoul emphasize that future research “should hypothesize pathways connecting communication to health outcomes.”²

^1. Goske MJ, Reid JR, Yaldoo D et al. RADPED: an approach to teaching communication skills to radiology residents. Pediatr Radiol 2005; 35(4) 381-386.

^2. Streeter RL, Makoul G, Aurora NK et al. How does communication heal? Pathways linking clinician-patient communication to health outcomes. Patient Educ Couns 2009 Jan 14 (Epub ahead of print)

Practice Improvement Tool: This PQI module provides a parent to radiologist information sheet you may download and use for your practice. This may be scanned into your PACS for the radiologist to review or become an electronic form in your PACS. LINK__CT Protocol and Parent Questionnaire

Practice Improvement Plan: Write your practice improvement plan in the box below.For example, I will use the Parent Information Questionnaire provided in my practice.

Metric 4 Documentation of LMP/ pregnancy test status prior to performance of CT scan

This metric evaluates the practice of screening for pregnancy in females 12 years of age and older. Radiation protection to the fetus is a core concept of the ALARA principle.

The goal of this metric is 100% compliance at Level/ score 2.

SCORE: 

0          LMP or recent HCG is not documented

1            LMP is documented but there are no initials of person making inquiry

2          LMP/HCG is documented, initialed by technologist and archived and easily         accessible by the interpreting radiologist

N/A       Not applicable ( male, pre-menarche female)

EVIDENCE BASED MEDICINE

In 2005, De Santis¹ et al published a review article of data available concerning prenatal exposure to radiation. This article focuses on fetal effects of maternal ionizing radiation exposure as it relates to congenital anomalies and birth weight. Effects of ionizing radiation have been found to be dependant on dosage and gestational age at time of exposure. It is advised that all radiology facilities have a written process to assess whether women of child-bearing age are pregnant, should have a plan for managing these patients, and should possess scientific references regarding radiation dose in their department². Further, it is suggests that all imaging equipment be well maintained, and any discussion with the patient be documented in the chart.

The ACR Practice Guideline for Imaging Pregnant or Potentially Pregnant Adolescents and Women with Ionizing Radiation is a detailed guide for methods to screen and handle concerns for pregnancy in your practice. This guideline emphasize that no screening policy will guarantee 100% detection. Furthermore, different screening policies might apply for high-dose versus low-dose procedures.

^1. De Santis M, Di Gianantonio E et al. Ionizing radiations in pregnancy and teratogenesis A review of the literature Reproductive Toxicology 2005; 20:323 LINK PDF

^2. Berlin L. Radiation exposure and the pregnant patient. AJR 1996; 167:1377  LINKPDF

^3. http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines/dx/Pregnancy.aspx

PRACTICE IMPROVEMENT TOOL: The American College of Radiology has developing a practice guideline entitled, “ACR Practice guideline for imaging pregnant or potentially pregnant adolescents and women with ionizing radiation “(2008 Resolution No. 26) that may be accessed via this link:http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines/dx/Pregnancy.aspx. Review of this guideline relative to your practice/ institution’s guidelines can be performed.

This PQI project has a pregnancy guideline from one children’s hospital that may be used to create your own policy. LINK SAMPLE pregnancy policy

Practice Improvement Plan: Write your practice improvement plan in the box below. For example, I will use the Parent Information Questionnaire provided in my practice to document questions pertaining to possible pregnancy.

Metric 5 Documentation of history of renal disease and/ or renal function.

This metric explores the radiologist’s knowledge of the patient’s renal function, either by inquiry into past history of renal disease or knowledge of the patient’s creatinine. Children’s creatinine level varies with age. A normal adult creatinine level in an infant is abnormal. While the incidence of contrast induced nephropathy is less common in children than adults, it remains one of the more common causes of acute renal failure in children.

      The goal of this metric is 100% compliance at Level/ score 3.

            SCORE:

0          No documentation of renal history and/ or renal function

                          1        Laboratory tests available in electronic medical record but not

            easily accessible by the interpreting radiologist

2          Renal history documented and/or laboratory values archived and easily   accessible by the interpreting radiologist

3          Renal history documented, laboratory values archived, reviewed by radiologist,   and acted upon appropriately. ( Example: elevated creatinine noted, nephrologist            consulted, decision made on appropriate use, communication documented in             patient radiology report or medical record.)

EVIDENCED BASED MEDICINE: 

Serum creatinine is a widely used but imperfect guide to a patient’s renal function. Unlike the glomerular filtration rate (GRF) which is more cumbersome to calculate/ obtain, but more accurate, the serum creatinine is a snapshot in time of patient’s renal function relative to their muscle mass. It may be normal in patients with moderate renal failure. In addition, normal serum levels creatinine must be adjusted for patient age.

In one laboratory, serum creatinine levels were as follows:

  0-9 years   < 0.7 mg/dL

10-13 years < 1.0 mg/dL

13-19 years < 1.2 mg/dL ¹

Go to this link for a simple GFR calculator. http://www.kidney.org/professionals/kdoqi/gfr_calculatorPed.cfm

A recent metanalysis provides a table of brand and generic names of contrast and reviews current thinking about contrast induced nephrotoxicity in ADULTS^{. 2}

Cohen et al discusses the use of metformin, an oral agent used in diabetic children. It can induce severe lactic acidosis in children with renal failure. Metformin may be stopped 48 hours prior to the use of intravenous contrast in diabetic patients.

^1. Haight AE, Kaste SC, Goloubeva OG et al.  Nephrotoxicity of Iopamidol in Pediatric, Adolescent, and Young Adult Patients Who Have Undergone Allogeneic Bone Marrow Transplantation. Radiology 2003; 226; 399-404

^2. Heinrich MC, Haberle L, Muller V et al.   Nephrotoxicity of Iso-osmolar Iodixanol Compared with Nonionic Low-osmolar Contrast Media: Meta-analysis of Randomized Controlled Trials. Radiology 2009; 250; 68-86

Cohen MD. Imaging the Pediatric Patient Contrast Agent Safetye. International Center for Postgraduate Medical Education. Free CD ROM available at http://courses.icpme.us/class_learn?course=72

PRACTICE IMPROVEMENT TOOL: The American College of Radiology has developed a “Manual on Contrast Media “(2008 Version 6) that may be accessed via this LINK http://acr.org/SecondaryMainMenuCategories/quality_safety/contrast_manual.aspx. Review of this guideline relative to your practice/ institution’s guidelines can be performed.

PRACTICE IMPROVEMENT PLAN: (Suggestions include: Review method by which radiologist accesses renal history. Review pediatric creatinine values by age at your lab.

Metric 6 Documentation of allergy history prior to administration of intravenous contrast

This metric evaluates the past history of the patient for contrast allergy, asthma or other allergies or conditions that may predispose the patient to an allergic reaction from intravenous iodinated contrast. While the incidence of anaphylaxis from contrast is rare in children, it remains potentially life-threatening concern.

     The goal of this metric is 100% compliance at Level/ score 3.

            SCORE:

0          No documentation of allergy history  

                          1        An inquiry into allergy history was made but not archived and the                                                            results are not easily accessible by the interpreting radiologist

2          Inquiry into allergy history was made archived and easily accessible by the                                 interpreting radiologist

3.         Allergy history documented, archived, reviewed and investigated appropriately by                       radiologist (Example: child with prior severe reaction, radiologist contacts                                   referring doctor and determines appropriate action. Communication documented                          In patient record)

EVIDENCED BASED MEDICINE:   A recent report of Dillman et al recently found an incidence of allergic reactions in 0.18% with low osmolality agents in 11,306 children, a rare event ¹.

They divide contrast reactions into two types:

1.) mild to moderate “side effects” such as nausea, vomiting, flushing, anxiety, local pain and extravasation   

2.) allergic reactions.

·         Allergic reactions are further sub-divided into:

o      mild (pruritus, cough, stuffy nose, sneezing, mild facial swelling and urticaria

o      moderate (symptomatic urticaria, hypertension, hypotension, mild edema of the larynx and mild bronchospasm which require some treatment

o      severe (laryngeal edema, bronchospasm, hypertension, pulmonary edema, cardiac arrest requiring prompt treatment.

PRACTICE PERFORMANCE TOOLS:

Karen Frush et al have provided an online pediatric resuscitation tool which may be downloaded for your practice. This includes normal values for pediatric vital signs and drug dosages and has been demonstrated in simulations in her practice to be readily implemented at the time of the contrast reaction. This is available through this link. (CREATE LINK)

^1. Dillman JR, Strouse PJ, Ellis JH. Incidence and Severity of Acute Allergic-like Reactions to IV Nonionic Iodinated Contrast Material in Children. AJR: 188, June 2007, 1643-1647. LINK PDF

^2. Frush K Pediatric resuscitation tool from Pediatric Radiology LINK PDF Have author permission.Need journal permission

Practice Improvement Plan: (Suggestions include: review location of pediatric emergency carts and set aside time for all personnel to review, have a simulated “code” in your department with your pediatric code team, download the Frush emergency algorhythms and post/download in your department.

Metric 7 Use of breast shields or technique modulation in girls / women.

This metric explores the use of shielding or technique modulation to reduce radiation dose to girls and young women. The most appropriate approach to reduce the radiation dose to breast tissue during CT scans may vary with the manufacturer of the CT unit. Consult with your manufacturer and medical physicist for guidance.

The goal of this metric is 100% compliance at Level/ score 2.

SCORE:

0          Breast shields or technique modulation procedures are not available

1          Breast shields or technique modulation were not used

2          Breast shields or technique modulation were used

N/A       Not applicable               

EVIDENCE BASED MEDICINE:     In 2003, Fricke et al published a paper that used bismuth breast shields in 50 pediatric patients undergoing multi-detector CT scans¹. This study indicated that all scans were of diagnostic quality and there were no perceptible differences between the scans in the shielded versus non-shielded lung. There was a 29% decrease in dose to the breast using their method. Beaconsfield demonstrated a dose reduction to the breast and thyroid gland when shielding was used during performance of a head CT². Note that in some scanners, such as those manufactured by Siemens, breast shielding may actually increase patient dose due to inherent auto exposure controls. The use of breast shields is not straightforward and varies with type of equipment. Likely, as CT equipment continues to evolve the use of breast shields may not be necessary. Some physicists suggest dropping the mAs and not using breast shields. Consult with your medical physicist to learn more about your equipment and the use of breast shields for your patients.

^1. Fricke BL, Donnelly LF, Frush DP et al. In –plane bismuth breast shields for pediatric CT: Effects on radiation dose and image quality using experimental and clinical data.

AJR: 2003; 180:407-411 LINK PDF

^2. Beaconsfield T, Nicholson R, Thornton A, et al. Would thyroid and breast shielding be beneficial in CT of the head? European Radiology1998; 8(4):664-667 NEED PDF

^3. Coursey C, Frush DP, Yoshizumi T Et al. Pediatric chest MDCT using tube current modulation: effect on radiation dose with breast shielding. AJR 2008; 190 (1): W54-61 LINK PDF

PRACTICE IMPROVEMENT TOOL: Consult with your medical physicist regarding the CT scans at your institution and whether or not breast shields are optimal.

PRACTICE IMPROVEMENT PLAN (I will consult with the medical physicist to investigate whether breast shields reduce radiation dose for pediatric patients on CT scanners at our institution.)

Metric 8 Single phase scans are adequate for most pediatric scan indications.

This metric explores the number of scan phases. For most pediatric body CT scans, single phase scans are adequate.

     The goal of this metric is 100% confidence at Level/ score 2.

SCORE:

0          Non-contrast, immediate IV contrast and delayed scans (multi-

                                     phase)  were performed      

1          Non-contrast and contrast scans were performed

2          Single scan was performed (non-contrast or IV contrast)

EVIDENCED BASED MEDICINE: CT scans provide timely medical information for children with life threatening illness. They are quick and easy to perform. However, attention to performance of the technique is important. Each phase of the CT protocol contributes to the radiation dose¹. Non-contrast and contrast abdominal CT scans are twice the radiation dose for the child. Single phase scans are usually all that is necessary in children in most instances ^{2, 3,}. Pre and post contrast scans or delayed imaging rarely provide additional information and should rarely be performed except in specific indications.

^1. Eduardo Just da Costa e Silva, Giselia Alves Pntes da Silva. Eliminating Unenhanced CT When Evaluating Abdominal Neoplasms in Children. AJR 2007; 189:1211-1214 NEED PDF

^2. Donnelly LF, Emery KH, Brody AS et al. Minimizing radiation dose for pediatric body applications of a single-detector helical CT: strategies at a large children’s hospital. AJR 2001; 176:303-306 LINK PDF

^3. Kaiser S, Finnbogason, Jorulf HK. Suspected appendicitis in children: Diagnosis with contrast- enhanced versus nonenhanced helical CT. Radiology2004; 231:427-433.

 PRACTICE IMPROVEMENT TOOL:  Scan protocols from two large children’s hospitals are free to download as a basis for which to review your scan protocols. (Need to obtain. Need permission) Review your standard protocols. Updates scan protocols to eliminate multi-phase scans. Discuss with Radiology technologists

PRACTICE IMPROVEMENT PLAN: Suggestions include “I will eliminate any protocols with multi-phase scans as a routine. Multi-phase scans should be done on a case-by case basis as specified by the radiologist.”

Metric 9 Radiation dose may be decreased by limiting scans to the portion of the body necessary to answer the medical question.

This metric reviews the scan length/body part ordered relative to the ordering doctor’s clinical history.

The goal of this metric is 100% compliance at Level/ score 2.

            SCORE:

0          One or more scan areas were obtained without clear cut indication

                                    (Example: upper abdominal pain. Patient received pelvis and/ or

                                    Chest

1          Indicated scan areas performed, but longer scan length was used

  (Example: breast, mid lung included in abdominal CT)

                          2        Scans performed correlated with indication and only indicated areas     

                                   Included in the scan

EVIDENCED BASED MEDICINE: CT scans of the entire body may be ordered due to the ease of performing the scan and the exquisite images obtained. This metric underscores the need for the radiologist to individually protocol CT scans for children. Only the indicated area should be scanned. Moore looked at trauma patients and in his series found little justification for including the chest CT  in requests for “total body scans”¹. Kalra advocates scanning only the area that is medically necessary ². Fefferman et al limits CT scans for appendicitis to below the lower pole of the right kidney ³. Taylor et al scans below L3 through the pelvis for appendicitis ⁴ . Some scans such as those assessing hip position after placement of a SPICA cast may be a very short in scan length.

^1. Moore MA, Wallace EC, Westra S. The imaging of pediatric thoracic trauma. 2009 Pediatr Radiol, published online January 17, 2009. LINK PDF

^2. Kalra MK, Naher MM, Toth TL et al. Strategies for CT radiation dose optimization. Radiology 2004; 230-619-628.LINK PDF

^3. Fefferman NR, Roche KJ, Ambrosino MM et al. Suspected appendicitis in children: focused CT technique for evaluation. Radiology 2001; 220:691-695

⁴. Taylor GA. Suspected appendicitis in children: In search of the single best diagnostic test. Radiology 2004; 231:293-295

PRACTICE IMPROVEMENT TOOL: The parent questionnaire provided in this PQI project includes a section for individual protocols for pediatric patients. Review your current protocols and determine if “routine” scan length may be shortened.

PRACTICE IMPROVEMENT PLAN: (After performance of this PQI project, I will individually protocol patients and shorten scan length where appropriate. I will use theCT Protocol Sheet/ Parent Information Questionnaire (provided in this PQI module) in my practice to document questions pertaining to possible pregnancy.

Metric 10  Radiation dose to patients may vary widely for the same CT examination on patients of similar size/age due to the use of varying technique, in particular mAs and kVP.

This metric reviews the consistency with which your practice follows your own protocols for patients of varying size/ age.

The goal of this metric is 100% at Level/ score 2.

SCORE:

 0         Our practice does not vary technique with the size/age of patient

 1         Our practice has technique charts or automated exposure control, but neither      was used for this patient

              2        Automated exposure control was used for this patient or the age/ size based                              technique charts at our institution was followed for this patient

EVIDENCED BASED MEDICINE: In 2001, Paterson et al published a study that examined “outside” CT scans of the body referred to their institution ¹. They concluded that pediatric helical CT parameters including tube current, kilovoltage, collimation and pitch were not adjusted for pediatric patients. In 2007, Arch and Frush published a survey of pediatric radiologists that indicated that the peak kilovoltage and tube current settings, the two principal determinants of radiation dose had decreased significantly compared to an earlier survey in 2001. ² They concluded that increased awareness about risks of radiation had contributed to this practice change. Many institutions have developed protocols to lower radiation dose based on size for pediatric patients. However, it is still the responsibility of the radiologists and radiologic technologist to implement these practices and follow size-based protocols for every patient.

^1. Paterson A, Frush DP,  Donnelly LF. Helical CT of the Body: Are settings adjusted for pediatric patients? AJR 176;February 2001; 297-301

^2. Arch ME, Frush DP. Pediatric Body MDCT: A 5- year follow-up survey of scanning parameters used byhttp://www.pedrad.org/associations/5364/files/Protocols.pdfediatric radiologists. AJR 2008;191,

PRACTICE IMPROVEMENT TOOL: Many manufacturers of CT equipment have automated exposure control that can optimize radiation dose reduction for pediatric patients. In equipment where this is not available, significant radiation dose reduction can be achieved by following size-based charts for pediatric patients. A universal size-based protocol is available on the Image Gently website. By working with your medical physicist, a size-based technique chart may be developed for your institution. A worksheet is provided on the Image Gently website (LINK http://www.pedrad.org/associations/5364/files/Protocols.pdf).

Your insititution may wish to decrease technique even more depending on radiologist’ comfort with increased noise on the CT scan image.

PRACTICE IMPROVEMENT PLAN (Write your plan in the box below. After performance of this PQI project, I will consistently use automated exposure control or follow size-based protocols for my pediatric patients.

LEARNING EXERCISE 11

What does the dose capture displayed on PACS represent?

Does CTDI give a display of individual patient dose?

CTDI  does not represent individual radiation dose to the patient but is a useful metric often displayed on CT scanners. This value is currently based on using a 32 cm diameter adult body phantom for body CT and a 16 cm adult head phantom for head CT and gives an index and acts as a “benchmark” that the adult PHANTOM would receive.

List the CTDI and phantom sized used (16 or 32cm) for the 25 patients in your study population.

Note that the CTDI does not vary for a given technique on the same scanner as it does not represent actual patient dose. CTDI is the same whether a 15 centimeter or 30 centimeter length of the body is exposed.

EVIDENCED BASED MEDICINE Nomenclature in radiology scanning parameters is problematic. The pros and cons of computed tomography dose index (CTDI) are discussed in an article by Brenner, McCollough and Orton¹. The American Association of Physicists in Medicine “The Measurement, Reporting and Management of Radiation Dose in CT”, is a good primer that discusses the various CT dose metrics.  The Medical Physics community is currently working to improve the current CTDI dose metric.

¹ Brenner DJ, McCollough CH, Orton CG. Is it time to retire the computed tomography dose index (CTDI) for CT quality assurance and dose optimization. Med Phys 2006 33(5); 1189-1191.

² The American Association of Physicists in Medicine  (AAPM) Report 96.The Measurement, Reporting and Management of Radiation Dose in C. New York. AAPM, 2008.

PRACTICE IMPROVEMENT TOOL Review the scientific terms available on the image gently website written by Donald Frush et al. (LINK word document http://spr.affiniscape.com/associations/5364/files/Community%20Radiologistsforweb.pdf)

and the discussion of various dose estimates as it relates to CT

PRACTICE IMPROVEMENT PLAN (Suggestion: I will review the above document on the image gently website. I will look at the dose capture display on my CT scanners in PACS to improve my understanding of CT dose display.)

  Thank you for participating in this practice quality improvement project.

Once you have obtained baseline data and used the learning tools and practice interventions to improve your practice, you will have completed cycle one and this learning exercise.

You may wish to develop another cycle of improvement related to reviewing pediatric chest or head CT scans in your practice on your own.

Thank you for completing this first cycle of improvement for body CT in children.