The National Academies 2009 Gilbert W. Beebe Symposium

Image Gently:Image Gently:A Template for ChangeA Template for Change

Donald P. Frush, MDPediatric Radiology

Duke Medical CenterDurham, NC

I consider the radiologist’s responsibility with (radiation) dose to be the same as any physician’s

with (medication) dose.

Over (or under) dosing is a medical error.

What can we do in medicine when we want to improve patient care?

Promoting CHANGE throughCommunication Campaign

Increase knowledgeAlter societal attitudes, andAchieve change

Define Image GentlyMeasuring successIdentifying contributing factors

The problem

CT scans in children Performed oftenIncreasingPerformed using adult techniques

Pediatric 64-slice MDCT

Pediatric 64-slice MDCTED (mSv) SD (mSv)

Chest w/ modulation 3.05 0.14

Chest w/o modulation 3.05 0.14

Chest Extreme 42.95 !!! 0.55Abdomen w/ modulation 7.32 0.33

Abdomen w/o modulation 6.34 0.35

Abdomen Extreme 118.9 !!! 1.85

http://www.nytimes.com/2009/10/16/us/16radiation.html

Increased Pediatric CT in the Emergency Department

Broder et al. Emerg Radiol 2007; 14:227-32

CT: Patterns of UseCT: Patterns of Use

30 - 65 million examinations in U.S.U.S. : 25 - 60% of world totalUp to 11% of CT exams are pediatric

4-7 million pediatric CTs17% of these in children 0-5 years old

MultidetectorMultidetector CT: U.S.CT: U.S.65,000,000 examinations per yearIf 50% involve two phases ….97,500,000 “dose events” per year2002 US population: 281,000,0001 CT for every 3.5 people

What is Image Gently?A Campaign by….Alliance for Radiation Safety in Pediatric Imagingof education and awarenessADVOCACY

To improve radiation protection for children 52 health care organizations/agencies (11/09)>700,000 participants worldwide: radiologists

radiology technologistsmedical physicists

Background2006 – Concept: The Society for Pediatric Radiology 2007 - ASRT, ACR, AAPM co-founding partnersFall 2007 - Alliance partnershipJanuary 2008 – CT rollout: “Image Gently” CampaignAugust 2008 – CT vendor summitJanuary 2009 – Parent brochureAugust 2009 – Pediatric interventional rollout

Steering committee

Marilyn J. Goske MD, ChairKimberly E. Applegate MD, MS Jennifer Boylan, MA Dorothy Bulas, MDPriscilla F. Butler, MSMichael J. Callahan MD Brian D. Coley, MD Shawn FarleyDonald P. Frush MD

Marta Hernanz-Schulman MDNeil D. Johnson MDSue C. Kaste DOCeela McElvenyGregory Morrison, CAE, MA

RT(R), CNMTKeith J. Strauss MS

Strategy ChairsManrita Sidhu InterventionalStephen Don CR/DRTed Treves Nuclear MedicineMarta Hernanz-Schulman Flouro

Alliance for Radiation Safety in Pediatric ImagingAcademy of Radiology ResearchAmerican Academy of PediatricsAmerican Board of RadiologyAmerican Board of Radiology FoundationAmerican Institute of Ultrasound in MedicineAmerican Osteopathic College of RadiologyAmerican Registry of Radiologic TechnologistsAmerican Roentgen Ray SocietyAmerican Society of Emergency RadiologyAmerican Society of Head and Neck RadiologyAmerican Society of Pediatric NeuroradiologyAsia-Oceania Federation of Organizations for Medical Physics (new 9/16/2009)Asian-Oceanic Society for Paediatric RadiologyAssociation of Collegiate Educators in Radiologic Technology(new 8/27/2009) Association of University RadiologistsAustralian & New Zealand Society for Paediatric RadiologyCanadian Association of Medical Radiation TechnologistsCanadian Association of RadiologistsCanadian Interventional Radiology AssociationCanadian Organization of Medical PhysicistsCoalition for Imaging and Bioengineering ResearchCollege of Radiology, Academy of Medicine of MalaysiaConference of Radiation Control Program Directors

European Society of Paediatric RadiologyHealth Physics Society (new 10/8/2009) Indian Society of Pediatric Radiology (new 9/25/2009) International Atomic Energy Agency (new 9/14/2009) International Radiology Quality Network (IRQN)International Society of Radiographers and Radiological TechnologistsInternational Society of Radiology (new 8/20/2009) National Council on Radiation Protection and MeasurementsNorth American Society for Cardiovascular ImagingRadiological Society of North America.The Royal Australian and New Zealand College of RadiologistsSociety of Interventional RadiologySociedad Latino Americana de Radiología PediátricaSociedad Mexicana De Radiologia E ImagenSociedad Española de Protección Radiológica (new 10/23/2009)Society for Pediatric Interventional RadiologySociety of Computed Body Tomography and Magnetic ResonanceSociety of Gastrointestinal RadiologistsThe Society of Nuclear MedicineThe Society of Nuclear Medicine - Technologist SectionSociety of Radiographers of Trinidad and TobagoSociety of Radiologists in UltrasoundSociety of UroradiologySoutheast Asia Federation of Organizations for Medical Physics

MessageCT helps us saves Kids' lives!But, did you also know...

When you image, radiation matters! Children are more sensitive to radiation What we do now lasts for their lifetime

So, when you image, image gentlyMore scanning is usually not better When CT is the right thing to do:

Child size the kVp and mA One scan (single phase) is usually enough Scan only the indicated area

Message

Role of the Technologists

OutreachTechnologistsVendorsRegulators

Education Standards Ultimate goal: Change Practice

Greg Morrison, CAE, Chief Knowledge Officer, ASRT

Role of the Qualified PhysicistKeith Strauss, Medical Physicist, Boston Children’s Hospital

Abdomen Basel ine:

kVp= 120 mA= 200 Time= 0.5 sec Pitch Abd omen= 1 Pitch Thorax = 1

Abdomen Thorax PA Thickness

(cm)

Approx

Age mAs Reduction

Factor (RF) Estimated mAs =

BL x RF (fill in) mAs Reduction

Factor (RF) Estimated mAs =

BL x RF (fill in) 9 newborn 0.31 31 0.29 29

12 1 yr 0.36 36 0.34 34 14 5 yr 0.61 61 0.57 57 16 10 yr 0.71 71 0.63 63 19 15 yr 0.77 77 0.69 69 22 small adult 0.91 91 0.84 84 25 med adult Basel ine (BL) 100 0.93 93 31 large adult 1.33 133 1.21 121

kVp= 140 mA= 400 Time= 0.5 sec Head Baseline: Pitch= 1

Head PA Thickness

(cm)

Approx

Age mAs Reduction

Factor (RF) Estimated mAs =

BL x RF (fill in) 12 newborn 0.47 94 16 2 yr 0.83 166 17 6 yr 0.93 186 19 med adult Baseline (BL) 200

Define Image GentlyMeasuring successIdentifying contributing factors

The Alliance for Radiation Safety in Pediatric Imaging

Website has been visited Website has been visited 99,234 times99,234 times

The protocol has been The protocol has been downloaded over 9,439 downloaded over 9,439 timestimes

2058 medical professionals 2058 medical professionals have taken the pledgehave taken the pledge

Image Gently:Activities and Accomplishments

Parent Information

Image Gently:Activities and Accomplishments

Parent InformationTranslations

9 languages: Arabic, Chinese-traditional and Mandarin, German, Korean, Portugese, Spanish, Thai, Turkish

Planned: Dutch, French, Hindi, Japanese, Tagalog, Urdu, Polish

فحص األشعة برفق

Image Gently Pledge والتزام تعهد

جري فحص األشعة برفق ارغب أن أأجل ، Yes, I want to image gently.

أن آل فرد في فريق الرعاية الطبية، يلعب دورا حيويا برعاية المريض، يانطالقا من معرفت ويطمح دائما لتقديم أفضل رعاية له، فإننى أتعهد:

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:

تواصل أعضاء فريقناتحادث وآون رسالتنا لــ "فحص األشعة برفق "على رأس أولوياتنا عند تأن

الطبي في هذا العام.to make the image gently message a priority in staff communications this year

)أو البروتوآوالت المقترحة( وإذا استدعت الضرورة فسوف نقوم أن نقوم باستعراض التوصياتبتعديل اجراءاتنا لتتوافق مع هذه التوصيات المقترحة من قبل الحملة .

to review the protocol recommendations and, where necessary, implement adjustments to our processes

أن نحترم ونستمع إلي االقتراحات المقدمة من آل فرد من أعضاء فريق الفحص باألشعة حول سبل

ضمان إجراء التعديالت المنشودة.to respect and listen to suggestions from every member of the imaging team on ways to

ensure changes are made أن نتواصل مع أولياء األمور بشفافية.to communicate openly with parents

لآم جزيل الشآر علي التزامآم بالهدف المنشود من حملة "فحص األشعة برفق "عند إجراء فحص

األشعة لألطفال أو عالجهم.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 تخصصآم أو في المستشفيأو العيادة التى تعملون بها

Spread the word in your department, practice, hospital or clinic.

* First Name اإلسم األول -

* Last Name اسم العائلة )الآنية( -

Image Gently:Activities and Accomplishments

Parent InformationTranslationsIR Campaign (August 24, 2009)

Image Gently:Activities and Accomplishments

Parent InformationTranslationsIR Campaign (August 2009)PQI Project

911

5

CT Radiations Safety PQI ResponsesMetric 2: Parent/Patient Education Provided

0

5

10

15

20

25

No parent Ed. materials

provided or available

Parent Ed. available on web,

but may not have been viewed

Parent Ed. provided at time of

scan or by mail and

documented

Mean for all Practices

My Practice

My Practice Compared to the Mean

Image Gently:Activities and Accomplishments

Parent InformationTranslationsIR Campaign (August 2009)PQI ProjectNQF: revisions for 2010 “Safe Practices”

Image Gently:Activities and Accomplishments

Parent InformationTranslationsIR Campaign (August 2009)PQI ProjectMeetings:

WHO: Children and Environmental Health June 2009

Image Gently:Activities and Accomplishments

Parent InformationTranslationsIR Campaign (August 2009)PQI ProjectMeetings:

WHO: Children and Environmental Health June 2009Vendor Summit August 2008AAPM Aug 2009 CR/DR Summit February 2010 St. LouisAlliance Update 11-30-09 RSNA

Image Gently Vendor SummitAugust 20, 2008

• CTDI phantom sizes not relevant for children• Hinders quality health care for children• Current dose displays:

• non-uniform • confusing

Courtesy Keith Strauss, Boston MA

Meeting Consensus

Image Gently Vendor SummitAugust 20, 2008

Education ModulesFour modules with content developed by the AllianceVendor Specific modules developed by each of the four major CT vendors

GE Healthcare, Siemens Healthcare, Philips Healthcare,Toshiba Medical Systems

Image Gently Vendor SummitAugust 20, 2008

chest abdomen

SPR Survey 2001 vs 2006: kVp

SPR Survey 2001 vs 2006: mA

chest abdomen

Define Image GentlyMeasuring successIdentifying contributing factors

Some ChallengesSome ChallengesVolunteer recruitment/retentionFunding Maintaining Campaign success:

independence/integritycontainment

Language translations

Image Gently:Activities and Accomplishments

Parent InformationTranslationsIR Campaign (August 2009)PQI ProjectMeetings:

WHO: Children and Environmental Health June 2009

Image GentlyOrganization is critical

reputablestakeholder consensusindependent

Message is criticalimportantsimplepositive

Delivery is criticaluse media expertsuse electronic mediacontrol content (stay on message)control accesscontrol timing: roll outs

February 2009 rollout: increase insite access : 285%protocol downloads : 390% pledges : 135%

Success must be emblematic

Thanks