Implementation of quality assurance in diagnostic radiology in Bosnia and Herzegovina (Republic of Srpska)

Application of a quality control (QC) programme is very important when optimisation of image quality and reduction of patient exposure is desired. QC surveys of diagnostics imaging equipment in Republic of Srpska (entity of Bosnia and Herzegovina) has been systematically performed since 2001. The presented results are mostly related to the QC test results of X-ray tubes and generators for diagnostic radiology units in 92 radiology departments. In addition, results include workplace monitoring and usage of personal protective devices for staff and patients. Presented results showed the improvements in the implementation of the QC programme within the period 2001--2005. Also, more attention is given to appropriate maintenance of imaging equipment, which was one of the main problems in the past. Implementation of a QC programme is a continuous and complex process. To achieve good performance of imaging equipment, additional tests are to be introduced, along with image quality assessment and patient dosimetry. Training is very important in order to achieve these goals.     

Safety and efficacy for new techniques and imaging using new equipment to support European legislation: an EU coordination action

The past two decades have witnessed a technologically driven revolution in radiology. At the centre of these developments has been the use of computing. These developments have also been driven by the introduction of new detector and imaging devices in radiology and nuclear medicine, as well as the widespread application of computing techniques to enhance and extract information within the images acquired. Further advances have been introduced into digital practice. These technological developments, however, have not been matched by justification and optimisation studies to ensure that these new imaging devices and techniques are as effective as they might be, or performed at the lowest possible dose. The work programme of the SENTINEL Coordination Action was subdivided into eight work packages: functional performance and standards; efficacy and safety in digital radiology, dentistry and nuclear medicine, cardiology, interventional radiology, population screening/sensitive groups; justification, ethics and efficacy; good practice guidance and training; and project management. The intention of the work programme was to underwrite the safety, efficacy and ethical aspects of digital practice as well as to protect and add value to the equipment used in radiology.     

Does digital imaging decrease patient dose? A pilot study and review of the literature

The potential for decreasing patient dose is one of the main arguments for the justification of the cost of digital imaging equipment. However, the literature review with respect to patient doses using digital imaging modalities, presents conflicting results. During this study, patients' entrance surface doses were measured for three simple radiographic examinations, in European centres equipped with a computed radiography digital system. Results showed that doses between centres varied from 30% for chest LAT to 250% for chest PA examination. With the digital image quality criteria still under discussion, and with the post-processing parameters and/or image documentations varying, any dose comparisons between conventional/digital systems, as well as dose comparisons between different centre using digital units, are difficult. Clinical trials are required in order to define reference levels associated with quality of digital image necessary to address specific clinical requirements.     

Measurement of network effects from the EC SCIENCE/STIMULATION programmes

Each of the EC research programmes has to be evaluated with respect to their objectives. This paper describes the study of the effects of the SCIENCE/STIMULATION Programmes on all the laboratories that participated in contracts which were still running at the time of the study. The study was designed with special regard to the short time available. Nevertheless, it yielded sufficient data to justify a clustering of the laboratories networks in four classes as they looked before the contract and in six classes as they looked afterwards. Thus, the study provided quantification of the links among the laboratories.We find that the method is feasible within the constraints set, but we recommend that further theoretical work be done on the concept of networks as well as on the processing of the data and, more ambitiously, that more global studies be made possible by use of this method on other surveys.This work has been sponsored by the MONITOR programme of the Commission of the European Communities.This paper is made after a survey realized for the Evaluation Panel (CEC, DG XII) of Science and Stimulation Programmes, by SHS Consultants and the Crédoc (140, Rue du Chevaleret, 75013 Paris, France).     

Introduction to constancy check protocols in fluoroscopic systems

Reference dose or guidance levels are a well established approach to the reduction of patient doses in diagnostic radiology. There are two main methods of determining reference doses, one involves patient dose measurements and the other phantom dosimetry. The latter approach lends itself to the development of constancy test protocols, which may be used as part of an acceptance testing programme or to compare the performance of different imaging systems. Various constancy test protocols and procedures have been proposed and these are reviewed. The constancy test protocols developed within the DIMOND concerted action will be described in detail. The advantages and disadvantages of the various methods and approaches are compared and contrasted. The complementary nature of constancy check protocols with patient dosimetry studies is discussed.     

First results on patient dose measurements from conventional diagnostic radiology procedures in Serbia and Montenegro

The objective of this work is to assess patient doses for the most frequent X-ray examinations for the first time in Serbia and Montenegro. A total of 510 procedures for 11 different examination categories in 3 general hospitals were analysed. Mean and median entrance surface air kerma (ESAK) and kerma area product (KAP) values followed by mean effective doses were reported. Using X-ray tube output data, ESAK for each radiographic examination was calculated, as well as the effective dose for each patient. Except for chest PA examination, all estimated doses are less than stated European and International Atomic Energy Agency (IAEA) reference levels for simple radiographic examinations. For complex examinations involving fluoroscopy and radiography total KAP was measured and contributions from fluoroscopy and radiography were assessed. The study of KAP confirms that the dose level for complex fluoroscopy investigations is closely related to the technique and individual patient variation in terms of fluoroscopy time and number of radiography exposures. The obtained values are comparable to those reported in the UK. Survey data are aimed aid development of a national quality control and radiation protection programme for medical exposures.     

Justification in clinical radiological practice: a survey among staff of five London hospitals

This study represents a survey performed among staff who, according to the Ionising Radiation (Medical Exposures) Regulations of 2000 (IRMER), are responsible for justifying radiological examinations in the UK. The aim of the survey is to map the current situation regarding knowledge of risks from X-ray exposures and the criteria used for their justification. An anonymous electronic questionnaire was emailed to 219 radiologists and radiographers of five National Health Service hospitals. The questions were designed to investigate the way the sample group defines/assesses risk and benefit when justifying medical exposures, and to test their knowledge on radiation doses, risk communication, and on relevant national legislation. The majority of the respondents are aware of the relevant legislation/guidelines. Patient's medical condition, age and sex, and alternative techniques using less or no ionising radiation are the main criteria used for justification. However, when estimating the effective dose of various examinations in chest radiograph equivalents, the majority of the responses were incorrect. Although there is good knowledge of legislation around justification of medical exposures, there seems to be a lack of knowledge on radiation doses and risks among IRMER practitioners.     

School-based programmes for the prevention of drinking and driving: issues and results

In an effort to decrease alcohol-related driving accidents and fatalities among youth, many school-based programmes to prevent drinking and driving have been developed. These programmes would seem to have many important advantages, including being able to foster appropriate attitudes and behaviours at critical times before and during the formation of driving behaviours and drinking behaviours. The didactic assumptions of these programmes are examined in this paper, and evaluations are reviewed. Programmes based on accurate provision of information and non-threatening attempts to change attitudes, and on behavioural peer intervention techniques, consistently demonstrate knowledge gains, and in some cases appropriate changes in attitudes and self-reported behaviours, immediately following programme exposure. These effects often tend to dissipate with time. Since the impact of these programmes on traffic safety measures has not been examined, their development should be carefully monitored and evaluated until traffic safety benefits can be documented.     

A preliminary study into performing routine tube output and automatic exposure control quality assurance using radiology information system data

Data are currently being collected from hospital radiology information systems in the North West of the UK for the purposes of both clinical audit and patient dose audit. Could these data also be used to satisfy quality assurance (QA) requirements according to UK guidance? From 2008 to 2009, 731 653 records were submitted from 8 hospitals from the North West England. For automatic exposure control QA, the protocol from Institute of Physics and Engineering in Medicine (IPEM) report 91 recommends that milliamperes per second can be monitored for repeatability and reproducibility using a suitable phantom, at 70-81 kV. Abdomen AP and chest PA examinations were analysed to find the most common kilovoltage used with these records then used to plot average monthly milliamperes per second with time. IPEM report 91 also recommends that a range of commonly used clinical settings is used to check output reproducibility and repeatability. For each tube, the dose area product values were plotted over time for two most common exposure factor sets. Results show that it is possible to do performance checks of AEC systems; however more work is required to be able to monitor tube output performance. Procedurally, the management system requires work and the benefits to the workflow would need to be demonstrated.     

Minimum detectable dose as a measure of bioassay programme capability

This paper suggests that minimum detectable dose (MDD) be used to describe the capability of bioassay programmes for which intakes are expected to be rare. This allows expression of the capability in units that correspond directly to primary dose limits. The concept uses the well established analytical statistic minimum detectable amount (MDA) as the starting point, and assumes MDA detection at a prescribed time post-intake. The resulting dose can then be used as an indication of the adequacy or capability of the programme for demonstrating compliance with the performance criteria. MDDs can be readily tabulated or plotted to demonstrate the effectiveness of different types of monitoring programmes. The inclusion of cost factors for bioassay measurements can allow optimisation.     

Assessment of patient organ dose in CT virtual colonoscopy for bowel cancer screening

Justification and optimisation form the basic elements for the radiological protection of individuals for medical exposures. Justification includes the assessment of patient organ doses from which radiation risks are deduced. Medical radiation exposures are justified only in the case of a sufficient net benefit. For screening examinations, such as CT virtual colonoscopy, this implies that patient organ doses should be relatively low to minimise the radiation detriment. Image quality should be sufficient to maximise the potential diagnostic benefits. The Medical Exposures Directive places special attention on medical exposures as part of health screening programmes and examinations involving high individual doses to the patient, both of which apply to CT virtual colonoscopy. Technical factors were recorded for a series of patients having virtual colonoscopy on a CT scanner. In addition, the dose-length product was assessed. Patient organ doses were deduced using a CT dose calculation program. The typical effective dose was 7.5 mSv for male patients and 10.2 mSv for female patients. The effective dose is higher for female patients, as some gender-specific organs are irradiated during virtual colonoscopy. Each patient has two series of scans resulting in doses of 15 mSv for male patients and 20 mSv for female patients.     

Study of radiation induced cancers in a breast screening programme

It is demonstrated that screening mammography programmes reduce breast cancer mortality considerably. Nevertheless, radiology techniques have an intrinsic risk, the most important being the late somatic effect of the induction of cancer. This study was carried out in order to evaluate the risk to the population produced by the Comunidad Valenciana Breast Screening Programme. All the calculations are carried out for two risk models, UNSCEAR 94 and NRPB 93. On the one hand, screening series detriments are investigated as a function of doses delivered and other parameters related to population structure and X ray equipment. On the other hand the radiation induced cancer probability for a woman who starts at 45 years and remains in the programme until 65 years old is calculated as a function of mammography units' doses and average compression breast thickness. Finally, risk comparison between a screening programme starting at 45 years old and another one starting at 50 years old is made.     

Quality control of equipment used in digital and interventional radiology

Digital and interventional radiology are increasingly important areas of radiology. Quality control (QC) of such equipment is of particular importance to avoid unnecessary high doses and to help to achieve good image quality. Within the DIMOND III project, equipment requirements and specifications for digital and interventional radiology have been formulated. A protocol for QC tests has been drafted based on various national and international recommendations. Tests are included for various parts of the imaging chain, i.e. X-ray tube and generator, X-ray tube control system, laser printer and display station, and image quality and patient dose. Preliminary tolerance levels have been set for the various tests, after initial measurements. To check the suitability of QC tests and stated tolerance levels, measurements were made at the University Hospital Gasthuisberg in Leuven for equipment used for paediatric radiology and a unit used for chest examinations. The results of the various tests are reported.     

Central dose data management and analysis in IT-driven radiation protection strategies

The applications of information technology in health care are now widespread and continue to grow. Medical imaging is at the forefront of this revolution and the introduction of digital detection methods to replace film is now addressing the diagnostic X-ray market, the most routinely employed imaging modality. The introduction of picture archiving and communication systems, hospital and radiology information systems is well underway, and the integration of radiation protection initiatives into these developments is desirable. In north-west UK, a project aimed at developing and implementing IT-driven radiation protection strategies has been underway for the past 10 y. Such strategies are geared towards the support of European Commission patient dose directive 97/43 EURATOM, in particular the need to implement clinical audit, patient dose audit and to establish dose reference levels. This paper demonstrates the national and local requirements for establishing a central dose data management system for use in radiation protection strategies. In particular, such a system can help develop and support the role of a medical physics expert in optimisation. The scientific requirements for such an approach are presented in this paper, and a prototype system is described. Preliminary results obtained with the central data management facility are also presented and the implication for analysing multiple site dose data in optimisation strategies for digital radiographic technology is highlighted.     

A review of image quality and dose issues in digital fluorography and digital subtraction angiography

This paper addresses image quality and dose issues in Digital Fluorography (DF) and Digital Subtraction Angiography (DSA), commencing with a brief review of methods and protocols for image quality assessment in DF and DSA. The relative scarcity of standards and test protocols for unsubtracted DF is highlighted. Pooled results from a large number of quality assurance tests are then used to illustrate trends in the choice of radiation dose per image currently employed in typical DF and DSA work. It is concluded that, although relatively high doses per image may be justified in terms of image quality improvement for DSA, there is little justification for the large range of exposures used in DF for nominally identical examinations. It is argued that the use of high doses per image in DF would not be expected to offer an advantage in terms of image signal-to-noise ratio.     

Measurements of X ray absorbed doses to dental patients in two dental X ray units in Nigeria

Measurements of absorbed doses from radiographic examinations to various anatomical sites in the head and neck of patients with an average age of 45 years using intra-oral dental radiography have been carried out. LiF (TLD-100) dosemeters were used for the measurements of the absorbed dose. The measured absorbed doses to the various anatomical sites in the two units are reported, discussed and compared with results from the literature. Quality control measurements were also performed using a Victoreen quality control test device on the X ray units. The tube voltage accuracies for the two units were found to be within acceptable limits (less than +/- 10%). On the other hand the exposure time accuracies for these units have large deviations (>20%). These results and those that have been reported in the literature may be an indication that high patient doses are common in most dental X ray centres and countries. As a result of this, regular compliance and performance checks of dental diagnostic X ray equipment are essential in order to ensure proper performance and to minimise unnecessary patient and operator doses.     

Developing a virtual reality application for training nuclear power plant operators: setting up a database containing dose rates in the refuelling plant

Operators in Nuclear Power Plants can receive high doses during refuelling operations. A training programme for simulating refuelling operations will be useful in reducing the doses received by workers as well as minimising operation time. With this goal in mind, a virtual reality application is developed within the framework of the CIPRES project. The application requires doses, both instantaneous and accumulated, to be displayed at all times during operator training. Therefore, it is necessary to set up a database containing dose rates at every point in the refuelling plant. This database is based on radiological protection surveillance data measured in the plant during refuelling operations. Some interpolation routines have been used to estimate doses through the refuelling plant. Different assumptions have been adopted in order to perform the interpolation and obtain consistent data. In this paper, the procedures developed to set up the dose database for the virtual reality application are presented and analysed.     

A national programme for patient and staff dose monitoring in interventional cardiology

A national programme on patient and staff dose evaluation in interventional cardiology made in cooperation with the haemodynamic section of the Spanish Society of Cardiology has recently been launched. Its aim is to propose a set of national diagnostic reference levels (DRLs) for patients as recommended by the International Commission on Radiological Protection and to initiate several optimisation actions to improve radiological protection of both patients and staff. Six hospitals have joined the programme and accepted to submit their data to a central database. First to be acquired were the quality control data of the X-ray systems and radiation doses of patients and professionals. The results from 9 X-ray systems, 1467 procedures and staff doses from 43 professionals were gathered. Provisional DRLs resulted in 44 Gy cm(2) for coronary angiography and 78 Gy cm(2) for interventions. The X-ray systems varied up to a factor of 5 for dose rates in reference conditions. Staff doses showed that 50 % of interventional cardiologists do not use their personal dosemeters correctly.     

Approaches to establishing reference levels in interventional radiology

Reference levels in radiodiagnostics are a requirement stated by the Council Directive 97/43/EURATOM. Reference levels are also relevant for interventional procedures, in accordance with this Directive, which claims special attention to quality assurance programmes, including quality control and patient dose evaluations for special practices such as interventional radiology, to assess the convenience of corrective action depending on the measured doses. The present paper addresses a method of establishing reference levels in interventional radiology, in the framework of optimisation, discussing the ways of putting forward values with a degree of tolerance, to allow for procedure complexity, depending on patient pathology. The need for several estimators used together, namely fluoroscopy time, total number of images per procedure and dose-area product, is also emphasised, proposing a further skin dose estimate in case of risk of deterministic effects. Finally, a brief summary of principles is given for the correct management of reference levels in interventional radiology.