Getting Back to Imaging Basics
Addressing increased utilization and exposure.
By Kelly J. Fechter, MBA, BS, RT(R)(CT)
August 22, 2011
If you walk by a hot room filled with smoke and fire, would you automatically go in without taking precautions? Probably not. You would limit your exposure and caution anyone else from entering.
The same holds true for radiation exposure from diagnostic imaging. Just because you can't smell, see, or feel X-ray, does not mean that it is not there, nor should you proceed without caution.
We have, as a society, become complacent about our radiation exposure and its possible side effects. Advances in diagnostic and therapeutic imaging technology have provided us with numerous benefits; yet, there are some costs: the potential of overutilization and overexposure. With overutilization, comes increased exposure--they walk hand in hand. However, controlling the variables that attribute to overutilization will help decrease radiation exposure.
The overuse of diagnostic imaging can be linked to many factors, including the lack of well-coordinated care between providers, defensive medical practices, lack of training of ordering physicians, the overall culture of ordering diagnostic testing, and a laissez faire attitude toward radiation exposure. Many specialists in the field agree that a substantial fraction of imaging examinations are unnecessary and do not positively contribute to patient care.1
Professor Wilhelm Roentgen developed the first X-ray on his wife's hand in December 1895.2 As often happens with new technology (coupled with the unknowns on the principles of X-ray), fear and panic spread after his invention. After some time, these concerns eased due to the beneficial applications of X-rays by the medical community. As time passed, overall acceptance and complacency replaced fear and panic.
In the news
|We have fought endlessly for recognition and respect within our field from peers and the general public, and now is not the time to let our standards slide, writes author Kelly J. Fechter.
Over the past few years, though, there has once again been increased public concern about exposure to radiation from such sources as airport security and an elevated anxiety due to our own nation's nuclear power plants.
The overutilization of diagnostic imaging, mainly computerized tomography (CT), also is gaining notice. In 2007, more than 62 million CT scans were obtained in the U.S., including at least 4 million on children.1 Although the CT scanner provides high-quality images that help physicians make accurate diagnoses, overuse of CT scans can bring great health risks to patients. CT scans project 50 to 500 times more radiation dosage than a regular X-ray machine and it significantly increases the risk of developing cancer.3 A national survey indicated approximately 29,000 future cancers could be related to CT scans in the U.S in 2007 alone.4
The NY Times article, "X-rays and Unshielded Infants," pointed out the issues associated with protocol deviations of an institution's CT scanners, inadequate skill and education level of technologists, and the light regulation of RTs and other professionals in the field.5 This has had serious implications, as children's cells divide quickly and are more vulnerable to radiation's effects.
Other unfortunate events shed light on the dangers of radiation exposure. For instance, a 59-year-old schoolteacher awoke with a headache and went to her local emergency room, where she underwent CT imaging of her head.6 Due to mechanical issues with the CT machine, she received a dose of radiation approximately 100 times the dose from the average brain CT scan, 10 times the dose from average brain perfusion scan, and three times the daily dose of radiation treatment for brain cancer. She lost some of her hair and developed vertigo and confusion. Upon returning to the same ER, she received another CT scan. Ms. C. is now a plaintiff in both a federal class action suit against the CT scanner manufacturer and a state medical malpractice lawsuit.
In this time of increased apprehension of radiation, we as radiology professionals should be on the forefront of educating the public and our own personnel, as well as taking steps in reducing errors and addressing overutilization of imaging and overexposure to radiation.
The paternalistic view taken by the public with their health care has a portion to blame for this issue. The public has become complacent toward having diagnostic imaging ordered and performed. If a doctor orders a CT, they get one. For the most part, the public has no idea of the amount of radiation that a CT yields compared to an X-ray. No one is questioning if it is completely necessary to have a procedure that is substantially higher in radiation than some alternatives with no radiation, such as ultrasound or magnetic resonance imaging (MRI).
The public needs to have more say in what their doctors are ordering, and why. This will result from better education, which our profession can take the lead in providing. Then, patients will become more involved with their own care by understanding the consequences of their radiation exposures.
In a time when most professions seek intense credentialing and requirements for advanced education, radiology is falling behind. At this point, there is no federal mandate for RTs, and the American Registry of Radiologic Technologists (ARRT) is voluntary; but most employers require certification. Utilization of such modalities as CT and MRI are on the rise. However, according to the ARRT, three out of five CT techs are not registered. That is almost 29,000 RTs not registered in CT.7
As stated on the ARRT website, "Although the ARRT examination is a voluntary certification exam, many states use the scores in licensing decisions. Approximately two-thirds of the states have licensing laws covering the practice of radiologic technology."8 That leaves almost one-third of the states without licensing. Also from the ARRT: "Some employers and state agencies may require ARRT certification, but not necessarily current registration. Unless they require current registration by ARRT, employers cannot assume that the person has complied with the ethics requirements or the continuing education requirements."
On the horizon, the Consistency, Accuracy, Responsibility and Excellence in Medical Imaging and Radiation Therapy bill (CARE), will amend and enforce the Consumer-Patient and Safety Act of 1981. With the impending arrival of the CARE bill, national credentialing will become a possible standard for our profession.9 This will update regulations for people who perform medical imaging exams and presumably make medical imaging safer and less costly.
All imaging professionals are responsible for obtaining continuing education credits throughout their careers; however, the education obtained does not always address what is needed, namely recurrent reminding of radiation and its effects. The emphasis of this education must be placed back on addressing the issue of limiting the exposure to the public and ourselves. Radiation protection education starts in our radiology programs, and then during orientation and/or re-orientation within our places of employ, there is usually a quick lecture on radiation and its effects for all employees. However, the personnel administering the radiation need to be re-educated and/or continuously updated. This education of the radiology personnel needs to get back to basics. One suggestion is to have technologists participate in an annual update class on radiation protection, just as BLS/AED needs to be recertified.
Follow the leaders
The proactive approach toward educating on and in lowering imaging radiation dose has been taken by many organizations and institutions. Some examples include:
Zwanger Pesiri Radiology: A Personal Dose Card given to each patient after procedure is performed stating their procedure and its dose, and a description of comparative dose values of other radiation sources.
Siemens Medical: The Guide to Low Dose and Pediatric Imaging Solutions to Lower Dose; Somatom Definition AS CT: Utilizes adaptive dose shield, adaptive EKG pulsing, and adaptive cardio sequencing. Established CT protocols with prescribed dose limitations and set parameters; Combined Applications to Reduce Exposure "CARE" dose-reduction technologies.10-13
ASTRO: In February 2010, The American Society for Radiation Oncology (ASTRO) committed to a six-point patient protection plan that will improve safety and quality and reduce the risk of errors and misadministration associated with radiation treatment delivery.14
Alliance for Radiation Safety in Pediatric Imaging: Addresses the fluoroscopic imaging effects on children, stressing "pause and pulse." Pause and child-size the technique, use the lowest pulse rate possible, and consider ultrasound or MRI when possible.15
Some institutions also are performing internal audits of the doses from CT and X-ray radiation exposure. In order to address concerns of excess radiation exposure from CT scans, the FDA released some interim recommendations in December 2009 that require facilities to access whether their patients received excess radiation, to review their radiation dosing protocols, and to implement quality-control procedures to monitor the compliance of dosing protocols.16
All of the aforesaid proactive steps would be a key benefit given the new the Healthcare Reform Act, especially as it relates to Accountable Care Organizations (ACOs) that will be charged for caring for significant patient populations. Although provider participation in an ACO is purely voluntary, the Medicare Shared Savings Program will reward ACOs that lower health care costs while meeting performance standards on quality of care and putting patients first.17
'Do no harm'
The Hippocratic Oath states "do no harm." We as technologists, educators, administrators, and lobbyists for the profession of radiology have all taken a vow to this standard. We have fought endlessly for recognition and respect within our field from peers and the general public, and now is not the time to let our standards slide.
All this public exposure and increased regulation have made necessary the immediate action by all the players within the medical imaging field. As day-to-day responsibilities and tasks tend to become mundane, regimented, or overbearing for all personnel within radiology, we must not lose sight of the potential repercussions from utilizing imaging. We must not forget the analogy of that hot, smoky room, and we need to continue forward with a sense of respect for the benefits and the dangers of this technology.
Kelly J. Fechter, MBA, BS, RT(R)(CT), a licensed and registered radiologic technologist for 16 years, is presently a dedicated cerebrovascular technologist within Stony Brook University Medical Center in Long Island, New York.
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2. Miller A. The history of the X-ray. Available on: http://www.umw.edu.
3. Landro L. Radiation risks prompt push to curb CT scans. The Wall Street Journal.
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5. Bogdanich W, Rebelo K. X-rays and unshielded infants. Available on: http://www.nytimes.com/2011/02/28/health/28radiation.html.
6. Smith-Bindman R. Is computed tomography safe? N Engl J Med. 2010;363(1):1-4
7. Computed tomography . more and more report working in CT, but most without the credential. Available from: https://www.arrt.org/new/computedtomography.htm.
8. Certification: What is it? Certification vs. registration--what's the difference? Available from: https://www.arrt.org.
9. CARE bill FAQs. Available from: https://www.asrt.org/content/GovernmentRelations/CAREBill/faq_legislative.aspx.
10. Guide to low dose. Available from: http://www.medical.siemens.com/siemens/en_US/gg_ct_FBAs/files/brochures/Guide_to_Low_Dose_NEW_2011.pdf
11. Pediatric imaging solutions for physicians. Available from: https://www.med.usa.siemens.com/kidsaredifferent.
12. Adapts for complete dose protection. Available from: http://www.medical.siemens.com/webapp/wcs/stores/servlet/PSGenericDisplay~q_catalogId~e_-1~a_langId~e_-1~a_pageId~e_132707~a_storeId~e_10001.htm.
13. Innovation leadership in dose reduction. Available from: http://www.medical.siemens.com/webapp/wcs/stores/servlet/LandingPage?storeId=10001&langId=-11&catalogId=-11&catTree=100010&pageId=135630&_nc_showLayer=1.
14. ASTRO commits to six-point patient protection plan. Available from: http://cs.astro.org/blogs/astronews/pages/web-exclusive-astro-commits-to-six-point-patient-protection-plan.aspx.
15. Image kids with care. Pause and pulse: image gently in fluoroscopy. Available from: http://www.pedrad.org/associations/5364/ig/index.cfm?page=664.
16. FDA. FDA makes interim recommendations to address concern of excess radiation exposure during CT perfusion imaging. Available from: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/2009/ucm193190.htm.
17. Garner J. Accountable care organizations may revolutionize health care. Available from: http://dmeclegal.wordpress.com/2011/ 04/05/accountable-care-organizations-may-revolutionize-health-care.