All Aboard California’s Dose-reduction Locomotive
In September 2010, California Gov Arnold Schwarzenegger™ signed into law a measure mandating that radiologists include dose–length product or volume CT dose index in all reports. Such a development probably spurred many imaging service providers to begin thinking about radiation-dose–reduction initiatives, but Providence Saint Joseph Medical Center (PSJMC), Burbank, California, was already ahead of this game, with plans for a comprehensive dose-reduction program under discussion. Judy Fauria, MSHA, RT (R)(M)(CT), is the hospital’s director of imaging services. She notes that talk about devising a dose-reduction initiative kicked into gear when a Los Angeles, California-based hospital disclosed, in late 2009, 206 patients, over an 18-month period, had been exposed to eight times the normal radiation dose for their exams. “We knew then that it was time to be proactive,” she says. Currently in its infancy, PSJMC’s dose-reduction initiative encompasses all areas of imaging that utilize ionizing radiation to produce an image. The safety principle of using doses as low as reasonable achievable (ALARA) and the Image Gently™ pediatric imaging guidelines are consistently followed under the program’s umbrella. Among other precautions, ALARA protocols mean exposing patients to the lowest dose of radiation feasible for effective diagnostics and protecting patients from scatter radiation using lead aprons and shields. Fauria and her colleagues also regularly engage in efforts to educate referring physicians about the ins and outs of radiation dose and the need to pursue dose reduction whenever feasible. She says, “We communicate with physicians to make them aware that for certain diagnoses, an MRI or ultrasound exam may be more appropriate for certain diagnoses,” Fauria states. Technology Is Key In addition to expanding the scope and reach of the educational portion of the program to include not only more hospital staff, but the general public, PSJMC intends to incorporate technology that supports dose reduction. Over a period of five days in July 2011, it tested the FDR D-EVO® flat-panel detector from FUJIFILM Medical Systems USA (Stamford, Connecticut). Two similar systems were also evaluated, with the FDR D-EVO subsequently deemed the winner, based on the greatest value for the investment, Fauria says. The FDR D-EVO converts existing radiography equipment to DR, fitting into standard cassette holders and bucky devices with no modifications. Fauria hopes to have the unit in place shortly. It is estimated that FDR D-EVO afforded an approximate 50% reduction in radiation dose without compromising image quality. “In the test, we were able to use half the normal dose as for CR to achieve the same diagnostic quality with DR,” she says. “The dose-reduction benefits are all in the technology of the detector.” Specifically, the detector features a 150-micron pixel pitch and a wide, 16-bit dynamic range, with exposure times of up to 3.8 seconds. The sharp imaging and enhanced dose efficiency are derived from the vendor’s patented irradiation side sampling (ISS) technology. With the ISS method, the thin-film transistor (TFT) sensor is on the front side of the scintillation layer, rather than on the back side (as with the TFT sensors of existing panels), according to Fujifilm. The scattering and reduction of signals is thereby decreased. A precision coating technology optimizes the scintillation layer. “The second-generation plates further reduced patient radiation dose,” Fauria states. As for advantages not related to dose reduction, Fauria and Patrick Savarese, MSHA, RT (R)(CT)(MRI), the hospital’s imaging department operations manager, cite enhanced workflow efficiencies and the user friendliness of the D-EVO software. “The entire operation becomes easier when you do not need to go through layers and layers of screens to get the job done,” Savarese says. A nine-second cycle time, a five-second preview time, and eliminating the need to handle trays and cassettes significantly speed patient throughput, he adds. Our Responsibility Fauria and Savarese believe that while developing and executing a radiation dose-reduction program is complex and requires commitment from the entire health care team. Taking such steps remains imperative for imaging providers. “What many people—including some referring physicians—do not fully realize is that an order for a study is really a prescription for a dose of radiation,” Savarese says. “Risks versus benefits should be discussed with a patient prior to ordering an imaging study that requires radiation exposure. We are the professionals; we’re responsible for patients’ safety. As such, we need to perform procedures responsibly. A dose-reduction program is part of that.” Moreover, Fauria observes, the California law probably represents only the tip of the iceberg on the legal front. She foresees the passage of other legislation that will inevitably render dose-reduction measures and initiatives even more important in all imaging sectors. “As regulations evolve, and we evolve along with them,” she concludes. Julie Ritzer Ross is a contributing writer for Radinformatics.com.