Radiation Stewardship

Introduction

Welcome to the APSA Quality and Safety committee . This page is intended to help anyone who is interested in Quality Improvement (QI) pertaining to radiation stewardship.

Available toolkit projects are listed below. Many of the approaches described are evidence-based - some are not. These approaches have not been approved by APSA.

Projects

Radiographic Stewardship in Trauma

Unnecessary computed tomography (CT) scanning increases health care costs and places children at increased risk of fatal cancers. The University of Rochester aimed to reduce unnecessary CT imaging in pediatric blunt trauma patients by developing imaging algorithms (guidelines) and retrospectively validating them for efficacy and safety. These were then implemented prospectively as part of a QI project to reduce unnecessary scans.

Protocol:

  • Guidelines were created after literature review to reduce unnecessary radiographic studies.
  • Institutional buy-in was generated by validating the guidelines retrospectively for efficacy and safety and obtaining feedback from stakeholders.
  • Education was provided to staff, including trainees, regarding purpose and usage of the tools.
  • Algorithms were then implemented prospectively to guide management for traumatically injured children.
  • Periodic chart review was performed to identify imaging practices (outcome measure) and missed injuries (balancing measure).
  • Repeated Plan, Do, Study, Act (PDSA) cycles were carried out to improve compliance.

Resources:

Stakeholders: pediatric blunt trauma victims, pediatric trauma team, pediatric ED, pediatric radiology, orthopedic surgery, neurosurgery, PICU, hospital leadership, malpractice insurer

Challenges and Solutions:

  • Challenge #1: Changing the culture in the ED from pan-scanning to selectively scanning based on mechanism, signs, symptoms, and other data (lab and radiographic).
    • Solution #1: Meeting with all stakeholders and addressing their concerns. Meeting with peds ED and surgical residents and explaining the rationale for the change in practice. The attached PowerPoint presentations were used to educate the residents and peds ED staff about the project. We also used this time to listen to and address their concerns, which likely improved buy-in.
  • Challenge #2: Getting providers easy access to the guidelines.
    • Solution #2: Widespread dissemination in the ED and to surgical residents. Creating an electronic web based calculator.
  • Challenge #3: Building in a process measure to determine if the guidelines are being used.
    • Solution #3: A web calculator was built that tracks when the online version of the guideline is used. We are looking into building a pediatric trauma imaging order set with a prompt and link to the guidelines before ordering CT scans.
  • Challenge #4: Improving adherence to the cervical spine algorithm. Initial reductions in unnecessary CT imaging were likely due to compliance with chest imaging.
    • Solution #4: In order to improve compliance further, we placed emphasis on adherence to the cervical spine guideline in July 2019 and started giving direct provider feedback for nonadherance in early 2020. Based on the run chart below, direct provider feedback seems to have caused a further reduction in the number of CT obtained that are not indicated by our guidelines.

Links to published data (used to develop the protocol): manuscripts are in preparation, please refer to the abstracts (under Resources) for presented work.

Submitted by: Derek Wakeman, MD

For additional information on guidelines pertaining to imaging, please refer to:

Intraoperative Radiation Reduction

Pediatric central venous lines (CVL) are frequently placed using fluoroscopy in the operating room. Few surgeons receive proper training on radiation protection, likely resulting in unnecessary radiation exposure to patients and staff. In order to minimize radiation, during and after CVL placement, Hassenfeld Children’s Hospital at NYU Langone instituted a strict fluoroscopic dose reduction intervention consisting of: (a) radiation safety training for staff; (b) implementation of a mandatory radiation safety time-out prior to C-arm use; and (c) limitation of postprocedural radiographs for asymptomatic patients. This initiative reduced the estimated radiation to the patient (as measured by DAP) almost fivefold. This decrease was corroborated by a nearly fourfold decrease in total radiation time.

Protocol:

  • A safety briefing to OR staff before each case which included information on the direction of radiation beams, dose reduction techniques, and the proper way to shield the patient and staff in the OR case
  • A time-out was performed before every procedure that required the use of a fluoroscopic C-arm
  • No post-operative CXR (final fluoroscopy image is saved to PACS)

Resources:

Stakeholders: pediatric surgery, pediatric radiology

Challenges and Solutions: Consistent adherence to the protocol was enhanced by use of the time-out protocol, using principles of structured surgical checklists, which have been shown to be low-cost, highly effective tools for improving patient outcomes and reducing complications.

Links to published data (used to develop the protocol):[25]

Submitted by: Sandra Tomita, MD

Decreasing CT Use in Appendicitis Patients

St. Joseph’s Children’s Hospital in Tampa developed a quality initiative focused on decreasing unnecessary CT scans while determining a diagnosis of appendicitis through assessment with the pediatric appendicitis score (PAS) and use of radiation-free diagnostic imaging. This initiative resulted from a review of the institution’s NSQIP Pediatric Semiannual Report that revealed a higher than average CT utilization and high negative appendectomy rate to CT utilization. A thorough literature review of best practices, current protocols for the diagnosis of appendicitis in ER, and imaging modalities used to diagnose cases in 2017, was undertaken. Moreover, surgeons reached out to other institutions to inquire about protocols being utilized. Thereafter, a multidisciplinary team was created which included emergency room physicians, radiologists and pediatric surgeons to create an algorithm for the diagnosis and treatment of appendicitis. The algorithm was presented at appropriate committees and was subsequently adopted as a best practice medical standard by the Health System.

Protocol:

Resources:

Stakeholders:

  • Medical Director of Pediatric Surgery, Grant Geissler, MD
  • Pediatric Emergency Medicine Physician, Worth Barbour, MD
  • Pediatric Radiologist, Timothy Bonsack, MD
  • Pediatric Hospitalist, Christina Canody, MD
  • Pediatric Surgical Program Coordinator, Kirsten Yancy, RN
  • Evidence Based Medicine Members: Paul Lewis, MD and Pamela Morell, RN

Challenges and Solutions:

Challenges:

  • Documentation of the PAS score by the ER physician in the EMR
  • Education to all ER physicians
  • Education to community ER physicians about best practice for the diagnosis of appendicitis

Solutions:

  • Working with the IT department to embed the PAS score in EMR documentation, providing education to ER physicians on consistently documenting the PAS score
  • Working on presenting the insitutional best practice medical standard to each Health System Hospital
  • Looking at opportunities for community education- work still in progress

Links to published data (used to develop the protocol): [26][27][28][29][30][31][32][33][34][35][36][37][38][39][40]

Submitted by: Grant Geissler, MD

Additonal Implementers: Kirsten Yancy, RN, BSN, CPN

In order to optimize the utility of ultrasound (US) at Children’s Healthcare of Atlanta (CHOA), a QI initiative was implemented consisting of the development and validation of a right lower quadrant ultrasound template that reported secondary signs (SS) and categorized diagnostic confidence and disease severity for acute appendicitis. Concurrently, the patients undergoing CT A/P and those being admitted for observation were also being tracked. The outcomes of interest included: high compliance rates of utilizing the standardized US report, lower CT A/P use, fewer admissions for observation, duration of symptoms was associated with more SS, and equivocal US that included hyperemia, fluid collection, or appendicolith had 96% specificity and 88% accuracy.

Protocol:

Resources:

Stakeholders: emergency department (ED), radiology, surgery, QI team

Challenges and Solutions: This QI initiative led to high compliance rates of utilizing the standardized US report and resulted in lower CT A/P use and fewer admissions for observation. We found that our colleagues in radiology were amenable to using the US template and had relatively easy/rapid implementation. We also found that both the ED and Surgery faculty/staff thought that the templated reports provided more detail and facilitated improved decision making.

Links to published data (used to develop the protocol): [41][42][43]

Submitted by: Mehul Raval, MD, MS

Additional implementers: Kurt Heiss, MD

Texas Children’s Hospital (TCH) also developed and validated an ultrasound scoring system for children with suspected acute appendicitis. The goal of standardizing the reporting of an appendiceal US by means of a structured template system was to risk-stratify patients with suspected pediatric appendicitis, and measure the effect of this scoring system on US diagnostic performance measures, follow-up CT exam rates and negative appendectomy rates.

Protocol:

Resources:

Stakeholders: emergency department (ED), radiology, surgery

Challenges and Solutions: The use of a risk stratification scoring system and structured template for reporting US exam results for suspected pediatric appendicitis improved communication of appendicitis likelihood to all the teams involved in the care of the patient. It did not seem to affect ED process measures such as total ED length of stay. Further analysis of data generated from this study allowed identification of factors that further discriminate between simple and perforated appendicitis based on the US.

Links to published data (used to develop the protocol): [44][45][46][47]

Submitted by: Monica Lopez, MD

Texas Children’s Hospital (TCH) also adopted Standing Delegation Orders (SDO) for US based on PAS scores assessed by ED triage nursing staff in order to minimize LOS in the ED phase of care. A surgical hospitalist pilot was launched concurrently with the goal of facilitating prompt surgical evaluations in the ED.

Protocol:

Resources:

Stakeholders: emergency department (ED), surgery, radiology, anesthesia, nursing, perioperative services, financial services, hospital administration

Submitted by: Monica Lopez, MD

At Nemours/Alfred I. DuPont Hospital for Children, a retrospective review was performed to identify patient characteristics associated with non-diagnostic ultrasounds in children with suspected appendicitis. Patients with a moderate PAS were likely to have non-diagnostic ultrasound, whereas, patients with high PAS were ikely to have appendicitis diagnosed on ultrasound. A hybrid approach to imaging patients with suspected appendicitis based on PAS was developed in which low PAS requires no imaging studies, moderate PAS get an MRI vs. no imaging, according to index of suspicion, and high PAS undergo an ultrasound. The current appendicitis imaging order (for MRI or ultrasound) has an embbeded PAS calculator, and requires input of the PAS.

Protocol:

Resources:

Stakeholders: surgery, radiology, ED

Challenges and Solutions:

  • ED hesitant to discharge kids without any imaging, even in low/moderate PAS groups.
  • Institutions must have experience and easy access to MRI 24x7.

Submitted by: Loren Berman, MD

In the evaluation of appendicitis, imaging is often obtained to confirm the diagnosis. While US is often considered a first-line imaging modality, there may be reasons, such as equivocal imaging or issues related to availability/reliability, that may prompt cross-sectional imaging (i.e., CT or MRI). Additionally, although US is often cited to have high diagnostic performance for appendicitis, recent studies have questioned its true sensitivity in clinical practice. At Penn State Children’s Hospital, the desire to avoid the potential radiation associated with CT scan, and the ready availability of MRI (Children’s Hospital within a General Health System sharing MRI resources) led to an investigation of MRI in the diagnostic evaluation of pediatric appendicitis. Based on the diagnostic accuracy and reliability of MRI in diagnosing or excluding appendicitis, characterizing alternative pathology, and facilitating ED disposition, as well as acceptable clinical time-related parameters (e.g., time from request to scan, imaging duration, time from request to interpretation), an appendicitis pathway was implemented and evaluated utilizing MRI as the primary imaging modality.

Key Results:

● 30 month institutional experience (n=510), 98% of patients ≥ 5 years old

● No IV/oral contrast MRI protocol

● Diagnostic Performance

o Sensitivity: 96.8%

o Specificity: 97.4%

o Positive Predictive Value: 92.4%

o Negative Predictive Value: 98.9%

● Time Parameters (median):

o Time from request to scan: 71 minutes

o Imaging duration: 11 minutes

o Time from last sequence to interpretation: 31 minutes

o Time from request to interpretation: 2 hrs

Protocol:

Resources:

Stakeholders: pediatric surgery, pediatric radiology, pediatric ED, ultrasound and MRI technologists

Challenges and Solutions: The program required buy-in from all pediatric surgeons, ED physicians, radiologists and technologists. Initially, coordination between the ED and technologists for scheduling MRI times, and interpretation was challenging, but improved as the MRI sequences were refined, timely MRI requests and scanning time became more predictable, and familiarity with the protocol grew. Additionally, skill in interpretation of appendicitis on MRI had to be developed and refined.

Links to published data (used to develop the protocol): [33][48][49][50][51][52][53][54][55][56]

Submitted by: Afif Kulaylat, MD, MSc

Recent Research

For recent research pertaining to radiation stewardship initiatives, please refer to the references

References

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