Prepare for new scrutiny on radiation safety as accrediting agency signals a need for added vigilance on this issue
IT tools help MGH make great strides on radiation safety
There was no one precipitating study or finding that prompted the Oakbrook Terrace, IL-based Joint Commission (JC) to issue a Sentinel Event Alert regarding the radiation risks of diagnostic imaging, stresses Ana Pujols McKee, MD, the JC's executive vice president and chief medical officer. Rather, the move follows a review of complaints received by the JC, surveillance of media reports, and discussions with health care organizations and consumers about this issue, she says.
"It is one of the ways the JC has to get accredited organizations to begin to pay attention to something," says McKee. Furthermore, she states that the move is a strong signal that the agency is likely to take a closer look at this issue. "We expect organizations to be more vigilant, and we want to educate more of our surveyors around radiation safety and to have them be more vigilant," she says. "I think we all have to change."
In issuing the Sentinel Event Alert, the JC noted that the U.S. population's total exposure to ionizing radiation has nearly doubled in the past 20 years.1 It further referenced a study suggesting that the 72 million computerized tomography (CT) scans performed in the country in 2007 could produce an estimated 29,000 future cancers and 14,500 future deaths related to ionizing radiation.2
Also of particular concern is the extent to which CT utilization is increased in the ED. As reported in the October 2011 issue of ED Management, one recent study suggests the use of CT increased by 330% between 1996 and 2007.3
Promote dialogue between radiologists and referring physicians
McKee acknowledges that curbing CT use in the ED is challenging because so many EDs have direct access to CT scanners, but she emphasizes that there are often safer alternatives available to referring physicians. Further, she suggests that these alternatives would be utilized with greater frequency if there was more dialogue between these physicians and imaging specialists. "The opportunities are there," she says. "What the Sentinel Event Alert is trying to do is increase the awareness that with every test there are options, and we need to start thinking about getting the best information with the least exposure to ionizing radiation."
The JC has not amended any of its existing standards regarding the safe and effective use of diagnostic radiation. However, McKee says the accrediting agency will be looking to its member organizations for ideas and strategies on ways to make further improvements on this issue. "We are looking at this as an opportunity to get organizations on board and to have them create processes that they feel are attentive to the safe use of ionizing radiation," she says. "There is nothing immediately in the pipeline, but we recognize this is an area that needs additional evaluation. We need to work more with organizations to get them to provide safe care."
Minimize duplicate tests
One organization that has, in fact, already made great strides in this area is Massachusetts General Hospital (MGH) in Boston, MA. The hospital says it has used information technology (IT) tools to reduce radiation exposure by as much as 95% for some exams. Furthermore, while use of imaging procedures has been rising steadily at most hospitals, it actually dropped by 25% from 2004 to 2007 at MGH.
Dushyant Sahani, MD, the director of CT at MGH and an associate professor at Harvard University in Cambridge, MA, says that key to the hospital's success on this issue is a computerized radiology order entry system that referring physicians use to order tests. "The system encompasses certain criteria which have been approved by the American College of Radiology that we call appropriateness criteria of ordering a test based on the clinical indications," he says.
Consequently, if a referring physician orders a test, the system will provide a score or a color code to let the physician know if a particular imaging test is appropriate for the clinical condition, explains Sahani. In addition, the system will let the physician know about any previous exams. "Let's say a patient had a recent CT performed," he says. "The system will alert the physician or the nurse ordering the exam that the patient had a recent CT, so that eliminates or minimizes any duplicate studies on these patients."
There are other safeguards as well. For example, a radiologist reviews all imaging tests that have been ordered to insure that the right protocols are being followed, says Sahani. "If we feel that MR [magnetic resonance imaging] would be better for a patient based on prior exams, then we can change the exam," he says.
Furthermore, MGH has outfitted all of its scanners with optimized protocols so that the dosing used on CT exams will be tailored to a patient's clinical need and body size, explains Sahani. "Therefore, we are not only providing an optimal diagnostic exam, but also cutting down the risks substantially for the overwhelming majority of our patients," he says. "Using a one-size-fits-all approach may be simpler and easier to implement in a busy practice, but it over-radiates many small-sized patients and young patients."
Newer scanners provide even more opportunities to reduce radiation doses without compromising diagnostic value, but Sahani acknowledges that the newer technology is also expensive. While MGH plans to eventually replace all of its scanners with the new machines, he acknowledges that cost is an obstacle. In the meantime, though, MGH is prioritizing the use of its three newer scanners for young patients, geriatric patients, and other patients who are potentially more vulnerable to radiation risks. "For the rest, we are using creative approaches of customizing the doses to ensure that they are quite low," he says.
Track physician behavior
In addition to providing valuable decision support at the time a test is ordered, the radiology order entry system enables MGH to track the ordering practices of referring physicians. "Radiologists don't order CTs. The referring physicians do," says Sahani. "But we now have the opportunity to see whether physicians are ordering appropriate tests, or if they are ordering too many of these tests."
This information has been helpful in educating referring physicians about their imaging practices, as well as in understanding why they are making certain imaging decisions, says Sahani. "There are physicians who see certain types of patients who are more challenging and complicated, or they have more imaging needs," he says, emphasizing that you have to look beyond the numbers. "But this has helped us to influence behavior in a positive way where some physicians have not realized that they are ordering a little bit more than their colleagues, and how their performance compares."
In particular, Sahani says radiologists have worked with MGH's ED physicians to the point where their utilization of CT has gone down, while MR and ultrasound utilization has increased, especially in pediatric patients and young women. Some ED physicians are even using handheld ultrasound devices to examine patients themselves for such conditions as kidney stones, says Sahani, although he points out that ultrasound visualization can be a challenge in larger patients.
"Behavior is certainly changing ... but having an accurate test like CT is still very useful in most patients who have certain kinds of acute presentation," explains Sahani.
Further, he stresses that implementing safe imaging practices requires collaboration. "All of us are in this together, and everyone shares the mission of how important it is that we take leadership and ownership of this area, and that we demonstrate to everyone that we take patient care and patient risks seriously."
- National Council on Radiation Protection and Measurements: Ionizing radiation exposure of the population of the United States (2009). NCRP Report No. 160, Bethesda, MD: 142-146.
- Berrington de Gonzales A, et al. Projected cancer risks from computed tomographic scans performed in the United States in 2007. Arch Intern Med 2009;169:2071-2077.
- Kocher K, Meurer W, Fazel R, et al. National trends of computed tomography in the emergency department. Ann Emerg Med 2011 Aug 9. [epub ahead of print]
- Dushyant Sahani, MD, Director of CT, Massachusetts General Hospital, Boston, MA, and Associate Professor, Harvard University, Cambridge, MA. E-mail: firstname.lastname@example.org.
- Ana Pujols McKee, MD, Executive Vice President and Chief Medical Officer, The Joint Commission, Oakbrook Terrace, IL. Phone: 630-792-5000.