Uno ‘Dose Trace’
By Keith Loria
Radiology Today
Vol. 23 No. 2 P. 22

Technological advancements are making dose-reduction protocols as easy as 1, 2, 3.

In recent years, dose safety quality control aspects such as CT protocol review and patient dose metric record keeping have been receiving increased emphasis from regulators and professional organizations. Dose safety is poised to remain an important theme in 2022.

“While the latest efforts in regulating these activities have focused on modalities with more standard reporting methods, it is reasonable to expect that these activities will continue to receive increased emphasis and extend across other radiology modalities such as fluoroscopy, planar X-ray, mammography, and MRI,” says Olav Christianson, MS, DABR, senior medical physicist at Landauer in Illinois.

Jim O’Brien, DABR, vice president and general manager of advanced applications and imaging physics for Fluke Health Systems in Georgia, notes while we rarely see acute effects in diagnostic imaging due to use of radiation today, there still can be some stochastic (probabilistic) effects, including an increased risk of certain types of cancer.

“So, while today’s equipment is far safer, it still is important to monitor radiation doses and implement a routine quality improvement program to reduce radiation dose and increase image quality,” O’Brien says.

With the increased regulatory emphasis on record keeping, advancements are being made to allow for more comprehensive documentation of dose metrics by radiology department dose-tracking software.

“Advancements are also being made using complex mapping algorithms and AI to aid in the statistical analysis of the recorded patient dose metrics,” says Brendan Loughran, PhD, DABR, medical physicist for Landauer.

Eric Radtke, vice president of sales and marketing for RADPAD, notes radiation exposure for health care workers has been on the rise for 40 years due to patient size (more mass equals more radiation to conduct the procedure and more scatter radiation to the staff); physicians performing some procedures very quickly—which means they will ultimately be doing more of them, leading to higher career doses; and brand-new technology and techniques that take time to master, which means longer fluoroscopy times until they are perfected.

“With today’s focus on immune system health and performance, you don’t want to compromise your immune system by receiving scatter radiation at work,” Radtke says. “In a similar fashion, the last two years have taken a toll on the mental health of medical staff, and studies indicate that radiation exposure leads to mental health issues such as anxiety, depression, and cognitive dysfunction.”

Getting Better All the Time
The Joint Commission implemented standards for diagnostic imaging safety for CT in 2015 and fluoroscopy in 2020. These standards require the use of medical physicists and have requirements for documenting patient radiation doses.

“These Joint Commission standards have driven significant reduction—as much as 20% or more—in patient radiation doses via surveillance and quality improvement,” O’Brien says.

Besides the Joint Commission standards, there have also been improvements in technology, including tube current modulation, kV modulation, iterative reconstruction for CT, pulsed beams, and automated collimation for fluoroscopy.

“These various techniques use mathematics to reconstruct images from lower-dose exams and can save 40% of the dose from older CT systems, and, in the case of fluoroscopy, the automated collimation can focus only where the physician really needs to see the detail and reduce doses by 25% or more,” O’Brien says. “As technology continues to evolve, I continue to see radiation doses be lowered while increasing the diagnostic value of these procedures.”

In the past, there were significant limitations on what types of dose metrics documentation could be accepted and recorded by dose-tracking software systems.

“Recently, machine learning–aided algorithms known as optical character recognition [OCR] are allowing for the documentation of metrics that fall outside of the typically accepted structured reporting,” Christianson says. “This is allowing for a wider breadth of imaging modalities and imaging machines to have their patient dose metrics documented for regulatory and quality improvement purposes.”

Advancements are also aiding quality improvement efforts by taking the recorded patient dose metrics and more quickly and accurately mapping the metrics to relevant dose benchmarks.

“Tasks that previously required significant time commitments to organize and analyze are now being completed nearly automatically using complex algorithms and AI,” Loughran says. “This leaves more time for radiology staff and dose safety experts to focus on the improvement of imaging protocols.”

Radtke notes radiation exposure in the lab can be managed and significantly reduced using shields, and now is very much the time to take the steps to reduce the risks of radiation exposure—particularly the chronic low-dose radiation often seen in the interventional suites.

“Time, distance, and shielding remain the proven ways to reduce radiation doses,” Radtke says. “Limit the time exposed to radiation, increase the distance from the radiation (which means between operator and patient), and, finally, shield yourself from radiation whenever possible.”

RADPAD has developed education programs for hospitals and their staff to learn about radiation and how to protect themselves from it during interventional procedures.

“Some hospitals have taken it upon themselves to implement best practices, such as [New York University] with their study ‘Utilization of a Radiation Safety Time-Out Reduces Radiation Exposure During Electrophysiology,’” Radtke says.

New and Improved
Jonathan Yifat, CEO of Radiaction in Tel Aviv, Israel, notes X-ray is here to stay. More complicated procedures are being performed under fluoroscopy that involve longer exposure, and the manufacturers are doing a good job in reducing radiation, he adds.

Still, he says that, for the medical team overall, the situation has gotten worse, with a number of studies showing early-age Alzheimer’s and cognitive degradation for those heavily exposed.

“I think it’s clear it’s only getting worse, so, for us, our mission is to save the lives of the medical teams,” Yifat says. “For the patient, it’s also an issue, but it’s usually a one-time deal. I know everybody’s trying to reduce patient exposure, and that’s, of course, important, but we are here for the medical team.”

Radiaction offers a device that provides full body protection, including the head, the arms, and the legs, to everybody in the room.

“The current situation with the standard protection, the hands are mostly unprotected. Sometimes they use a clear shield that provides some protection to the hands, but it’s debatable whether it’s 60% or 70%,” Yifat says. “The standard lead aprons protect everybody from chin to shin; of course, they have their own drawbacks, and they cause orthopedic injuries that are really a disaster for everybody. Anybody who works more than five to 10 years in the cath lab, a lot of studies show over 60% need orthopedic intervention.”

Radiaction’s solution blocks radiation for all team members in the room for the entire body, with tests showing it achieves approximately 92% protection overall, and around 96% for head protection.

The company’s product works because the shielding is at the source, instead of putting more barriers between the physician and the C-arm.

“Instead of wrapping the physician with additional layers of lead, whether they’re suspended on wheels or on them personally, we are mounted on the C-arm between the patient and the image in between the X-ray tube and the table,” Yifat says. “This is the source of the majority of the scatter radiation, and this is where our products actually block radiation.”

Currently, Radiaction is not available in the United States, but it is expected to be sometime in early 2022 and is already gaining popularity in Europe and Israel.

There are many ways to reduce radiation doses; some are implemented by the original equipment manufacturers and some are accomplished through education and careful enforcement of policies and procedures.

Landauer’s OPTIMIZE uses OCR, mapping algorithms, and AI to accurately document dose metrics from a wide breadth of imaging machines and modalities, Loughran says.

“Once documented in the OPTIMIZE ecosystem, these dose metrics are then mapped and compared to nationwide benchmarks,” he says. “Individual patient dose metrics are also compared to customizable radiation dose thresholds. Finally, OPTIMIZE provides expert medical physics support to assist with quality improvement and protocol review efforts.”

There have been some advancements in various shielding devices available to the market, but not all devices provide the same protection for everyone in the room. Some shields today hang from the ceiling or are mounted on the table.

Radtke notes RADPAD shields are one proven solution to reducing patient and operator radiation exposure on every procedure and for everyone in the interventional suite.

“Some of the latest advancements have been in AI and software to help collimate and focus imaging to reduce radiation exposure,” he says. “There are other shielding devices that attach to the C-arm that are marketed as reducing radiation doses. The challenge with these is, while they may protect one operator, they leave the rest of the team exposed. This is why RADPAD use continues to grow year after year, even through the pandemic when caseloads were down.”

Looking Ahead
Not surprisingly, the experts feel limiting dose is more important today than ever.

“Another reason it is so vital today and in the future is that studies indicate that radiation causes oxidative stress and chronic inflammation in the body and leads to immunosuppression,” Radtke says.

Advancements in both software technologies to improve record keeping and software technologies to assist with imaging quality improvement are expected to continue in the years ahead.

“We can expect that these advancements will allow for more comprehensive quality improvement insights across what will eventually be all imaging modalities,” Christianson says. “It will be important for imaging administrators to carefully consider and select dose tracking solutions and dose recording systems that are agile and comprehensive enough to meet future regulatory and quality standards.”

O’Brien notes that 2022 promises to be an exciting year for advancements in the area of image quality improvement and radiation dose reduction, as radiology is on the forefront of AI and machine learning.

“Many new software companies are devoted to use of these technologies to better utilize radiologists and radiology equipment,” O’Brien says. “We are working on new AI techniques to identify when protocols are changed, so our clients can be assured that the protocols used are correct and appropriate. We are also looking at ways to improve workflow and allow more efficient utilization of resources for radiology departments.”

— Keith Loria is a freelance writer based in Oakton, Virginia. He is a regular contributor to Radiology Today.