Knowledge of radiation exposure in common radiological examinations

amongst radiology department staff

AL Chang, LH Cope, DH Keane, S WoodPresented by Dr AL Chang at Royal College of Radiologists Audit Meeting 18 May 2015

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Disclosures

• Work performed at Radiology department South Tyneside NHS Foundation Trust (STFT)

• Current workplace – City Hospitals Sunderland NHS Foundation Trust

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Background

• The use of radiological investigations is an accepted part of medical practice justified in terms of clear clinical benefits to the patient, which should far outweigh the small radiation risks.

• However even small radiation doses are not entirely without risk. A small fraction of the genetic mutations and malignant diseases that occur in the population can be attributed to background radiation

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• The Ionising radiation (Medical Exposure) regulations 2000 and 2006 (IR(ME)R) impose a responsibility on imaging departments to ensure that all exposures to ionising radiation are justified, and that doses are optimized. Organizations and individuals using ionising radiation must comply with these regulations.

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Background

• Information available on internet• Heightened awareness of radiation exposure• iRefer available on intranet• Only a third of clinicians receive training in radiation

protection and the level of knowledge is low (Soye 2008)

• On 1 April 2009, the Care Quality Commission (CQC) assumed responsibility from the Healthcare Commission for the inspection and enforcement for incidents in England under Ionising Radiation (Medical Exposure) Regulations 2000

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• A single view chest x-ray gives an effective dose of 0.015mSv.

• This amounts to 2.5 days of background radiation

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THE STANDARD

• All radiology department staff should have knowledge of the relevant radiation doses for common examinations

Target• 50% awareness of dose estimation per chest x-

ray equivalent

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Process – Data collection

• Standard questionnaire (14 questions)

• To all staff in radiology department• Data collected over – First week November 2012– First week April 2014

• Number distributed– 1st round = 70 ; responders = 54 ( 77%)– 2nd round = 60 ; responders = 38 ( 63%)

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Results- respondersAudit 1st round

(Nov 2012)2nd round (April 2014)

Responders N = 54 38Consultant radiologist 3 3Radiology SpR 0 2Radiographer 18 13Radiology assistant 9 6Radiology nurse 0 0Administrative staff 17 7Student 3 5Porter 4 2

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Introductory question

• The IR(ME)R) regulations 2000 and 2006 impose a responsibility on imaging departments to ensure that exposures to the following imaging modalities are justified1. Plain x-rays2. Ultrasound scans3. Computed tomography imaging4. MRI scans5. Barium contrast studies6. All of the above

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Introductory question

• The IR(ME)R regulations 2000 and 2006 impose a responsibility on imaging departments to ensure that exposures to the following imaging modalities are justified1. Plain x-rays2. Ultrasound scans3. Computed tomography imaging4. MRI scans5. Barium contrast studies6. All of the above

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Results - dataIR(ME) R regulations 2000 & 2006

1st round 2nd round

Consultant radiologist 3/3 (100%) 3/3 (100%)

SpR radiology 2/2 (100%)

Radiographer 16/18 (89%) 12/13(92%)

Radiology assistant 7/9 (78%) 6/6(100%)

Admin Staff 4/17 (23%) 2/7(28%)

Student 4/4 (100%) 3/5(60%)

Porter 0/3 (0%) 0/2(0%)

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Segment II of questionnaire

What is the equivalent dose in ‘chest x-rays’ for the following examinations ?

For example

The equivalent dose from a single view pelvis x-ray is 20 chest x-rays

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AnswersApproximate Chest x-ray

equivalentExact valueiRefer 2012

Abdomen x-ray 50 30

Lumbar spine x-ray single lateral view

50 40

Ultrasound scan abdomen 0 0

MRI angiography 0 0

MRI brain 0 0

Barium Swallow 100 100

Isotope bone scan 200 200

CT brain 100 90

CT Chest 400 440

CT abdomen and pelvis 400 450

PET-CT body > 800 1200

iRefer – RCR 2012

16CT HEAD = approximate equivalent of 90 chest x-rays

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What is the additional lifetime risk of inducing a fatal malignancy by performing ……

CT chest abdomen and pelvis 1:2 000

A Chest x-ray 1:1 000 000

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Results

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Consultant

Radiologist (3)

Radiographer

(18)

Radiology

assistant (9)

Admin staff (17)

Porter (3)

Student (4)

0 1 11

2

3 3 14 1 15 2 1 1 16 1 17 1 6 1 3 28 69 1 1

10 1 111 1 1 112 113

Don’t know

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Consultant

Radiologist (3)

Spr radiology (2)

Radiographer (13)

Radiology

assistant (6)

Admin staff (7)

Porter

(2)

Student (5)

0

1

2 2 1

3 1 1

4 2

5 3 1 2

6 1 1

7 1 1 3 2 3

8 1 4 1 1

9 1 1 1

10 1

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13 1 1

Don’t know

0 0

1st round 2nd round

Distribution of number of correct answers

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Results Results Target - > 50% awareness

1st audit 2nd audit

Consultant Radiologist 3/3 (100%) 3/3 (100%)

SpR radiology 0 2/2 (100%)

Radiographer 15/18 (83%) 7/13 (53%)

Radiology Assistant 2/9 (17%) 4/6 (67%)

Administrative Staff 3/17 (17%) 3/7 (42%)

Portering Staff 0/3 (0%) 0/2 (0%)

Radiography Student 4/4 (100%) 4/5 (80%)

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Observations – first audit

• Admin staff and porters are of the opinion that Ultrasound and MRI examination involve radiation exposure

• 70% (12/17) of administrative staff respond ‘Don’t know’.

• Radiography Students (4) have performed well – max being 11/13

• Highest mark (knowledge) by a radiographer (12/13)• 7/13 is average score amongst radiographers - 53%

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Observations and Actions taken

• Awareness of radiation exposure in common radiological examinations amongst staff working in radiology department is poor

• 77% return of forms• Radiology nurses have not submitted form

• Lunch time lectures ( x 4) on procedures undertaken in the department and on IR(ME)R

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Observations – second round audit

• Maximum score obtained by 1 consultant radiologist and radiographer

• Radiology assistants – massive improvement in knowledge

– 100% in the IR(ME)R questions and

– 67% responders ( cf 17%) achieving > 50% score.

– 1 Rad assistant scored 9/13

• Admin staff demonstrate some improved knowledge in radiation awareness:

– No staff response of ‘Don’t know’.

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Observations – second round

• Radiographers

– improve on the IR(ME)R question

• (89% –> 92% correct)

– decreased awareness of radiation equivalents

• (83% -> 53% > 50% marks )

• Porters – very low awareness – no improvement.

• Radiology nurses have not submitted forms

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Further observations

• Admin staff indicated that

– MRI involved radiation (3)

– CT head, CT abdomen involved radiation dose equivalent > 800 CXR (5)

• Porters continue to believe that

– MRI and US involved radiation

– Barium swallow study involved no radiation.

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Further observations

• Students

– indicate CT head and CT chest dose equivalents > 800 CXR

– are aware that US & MRI involve NO radiation

– are aware that PET-CT involves very large dose > 800 CXR (100%)

• Overall knowledge of dose equivalent of CT head is poor (30% radiographers, 50% SpR)

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Limitation

• Reference - iRefer (2012) for validation of radiation doses and chest x-ray equivalents.

• However, these doses are relatively higher than STFT radiology in view of iDose in CT and Digital radiography.

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Staff Responses

• ‘Thank you for taking the time to inform us’– Admin staff

• ‘I now feel better equipped to answer patient questions’– Radiology Assistant

• ‘I am able to understand my job better’– Radiology Assistant

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Summary

• Overall there is good interval improvement in awareness of radiation dose equivalents amongst radiology assistants and admin staff.

• Staff feel valued

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Recommendations and Action plan

• Essential attendance at department lecture on procedures undertaken in the department and on radiation protection and Ionising (ME) regulations 2000 and 2006 to all staff

• Although some staff are not directly involved in radiation exposure, it is essential they are aware of these procedures as they work in a radiation designated area

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• My thanks to radiography student Sophie for distribution and collection of data sheets in radiology department in second audit cycle.

• Any questions or suggestions

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References

1. Soye & Paterson. A survey of awareness of radiation dose among health professionals in Northern Ireland. BJR 2008; 81: 725-729. http://bjr.birjournals.org/cgi/content/abstract/81/969/725

2. The Ionising Radiation (Medical Exposure) Regulations 2000. HMSO. http://www.legislation.gov.uk/uksi/2000/1059/pdfs/uksi_20001059_en.pdf

3. iRefer. Making the best use of clinical radiology 7th Edition RCR 2012 www.rcr.ac.uk/content.aspx?pageid=995