Real World Experience: Developing Dose and Protocol...
Transcript of Real World Experience: Developing Dose and Protocol...
RealWorldExperience:DevelopingDoseandProtocolMonitoring
fromScratch
IngridReiser,PhDDABRDepartmentofRadiologyTheUniversityofChicago
Outline
• CTprotocolmonitoring– Let’sbuildaprotocolbook!
• CTdosemonitoring
Fromscratch:statusasof~2015
• Fleetof8-9PhilipsCTscanners,mixofinpatient,outpatient,dedicatedpediatric• Radimetrics installed,about60%ofCTstudiesrecorded
• Events:– Majorsoftwareupgradeonsomescanners(PhilipsiPatient)– 3scannersreplaced,whichaddedGE– Openingofremotefacility
• Personneltransitions(CTmanager)• NodedicatedCTphysicist
CTProtocolMonitoringandOptimization
• Joint Commission Standard PC.01.03.01: The [critical access] hospital plans the patient’s care. A 25. The [critical access] hospital establishes or adopts diagnostic computed tomography (CT) imaging protocols based on current standards of practice, which address key criteria including clinical indication, contrast administration, age (to indicate whether the patient is pediatric or an adult), patient size and body habitus, and the expected radiation dose index range.A 26. Diagnostic computed tomography (CT) imaging protocols
are reviewed and kept current with input from an interpreting radiologist, medical physicist, and lead imaging technologist to make certain that they adhere to current standards of practice and account for changes in CT imaging equipment. These reviews are conducted at time frames identified by the [critical access] hospital.
JCrequirements
• CTQualityPolicywasestablished– CTQualityCoreTeamcreated,taskedwithprotocolanddosereview
Theprotocols
“Routine critical and systematic review of protocols are necessary not only to ensure that appropriate radiation dose levels are being used but also to verify that other aspects of are
acceptable and consistent with best practice standards.”
Protocolreview:Whatare ourprotocols?
Whataretheparameters?
J Am Coll Radiol 2014;11:267-270.
Theprotocols
“Routine critical and systematic review of protocols are necessary not only to ensure that appropriate radiation dose levels are being used but also to verify that other aspects of are
acceptable and consistent with best practice standards.”
– Typically>200imagingprotocolsperscanner– NeedtheactualCTprotocols
Theprotocols
“Routine critical and systematic review of protocols are necessary not only to ensure that appropriate radiation dose levels are being used but also to verify that other aspects of are
acceptable and consistent with best practice standards.”
– Typically>200protocolsperscanner– NeedtheactualCTprotocols– Notallvendors/modelsproduceaCOMPLETEhumanreadablelistingofprotocolparameters
Oursolution:gettingscannerprotocols
• Haveserviceengineerretrieveprotocolbackupfiles(Philips)• PhilipsiPatient softwareproducesatext-file(htmlformat)• GERevolutionCTseriesproducecsvfiles– incomplete
• noserieslabels• RevolutionCT:Nopitchfactor,protocolnumberingomitted
Usingtheprotocols(i.e.,reviewlogistics)
• Textprotocolformattingmaynotbeamenableforreview
• Radimetrics hasaprotocoleditor– Mayormaynotimportyourprotocolparameters
• Oursolution:– Parseprotocolsusingascriptinglanguage(python,matlab,etc)– Generateexcelmasterprotocolforeachscanner
Acquisitionparameters
Reconstructionparameters
Multiplevendors:Consistencyofprotocols
• Perfectparametermatchnotalwayspossible– GE:3.75mmsliceinterval– Philips:4mmsliceinterval
Currentbestpracticestandards?Acceptable
doselevels?
Radiologistsinindividualsections:
Physicist: Technologist/Radiologist:
protocolsparameters
Scaninstructions Consolidation,
Standardization
Notificationvalues Review:
appropriatedoseandimagequality
Approvalofprotocols
Theteam
“Protocol review and improvement efforts should be undertaken by a core team consisting of at least one radiologist, one physicist, and one technologist.”
• Radiologistcanonlyoverseeprotocolsrelevanttotheirsection– GenerallycannotapproveCTprotocolsforadifferentsection(i.e.,thoracicradiologistcannotapproveneuroprotocols)
J Am Coll Radiol 2014;11:267-270.
Theteam
“Protocol review and improvement efforts should be undertaken by a core team consisting of at least one radiologist, one physicist, and one technologist.”
• CTclinicalmanager(s)overseesCT– IsultimatelyresponsibleforthequalityofCTscansperformedbyhis/hertechnologists
– Has/shouldhaveaninterestinwelldocumented,standardizedCTimagingprotocols
– Supervisesandcommunicateswithalltechnologists• Hasfirepower
Theteam
“Protocol review and improvement efforts should be undertaken by a core team consisting of at least one radiologist, one physicist, and one technologist.”
• CTclinicalmanager(s)overseesCT– Cangetaccesstoscanners(masteroftheschedule)– Knowstheprotocols– ControlshowCTscannersaresetup(i.e.,passwordprotectionofprotocoleditor)
..DOpasswordprotectyourCTprotocols- allchangesaremadeinthebestintent..
Must-haves:
• Supportfromtheadministration:– Dedicated,protectedtechnologists’time($$)
• CTmanagersupportcritical– Appointsonededicatedtechnologist(“technicalcoordinator”)– Scheduling:protectedtimeOFFTHEFLOORtohelpwithprotocols
• Difficultiftherearestaffingshortages
– ControlsCTschedule(blockscannertimeforprotocolupdates,notificationsettings)
• Leadtechnologistmaynotbeideal,astheyalreadyhavemanyotherresponsibilities
Aprotocolbook
• Protocolbook:– Scaninstructions:Technologist/radiologist– Scanparameters:Physicist
• Protocolbookhelpsestablishstandard– Technologists’willchangescanparametersontheflybecauseA radiologistrequestedscanA tobedoneinacertainway..
Ourapproachtobuildingaprotocolbook
• Goal:Buildaprotocolbookthatisflexible,editable,allowingforautomatedupdatingofscanparameters
• Requirements:– Easyexchangewithtechnologists/clinicians(MSoffice)– Automatedscanparameterupdate
• Todisseminate:– UtilizeMSsharepoint
• Use.aspx extensiontodisplayhtml
Softwaretool
Data entry:clinicalinstructions
Data entry:scanparameters
Data entry:Scanparameterupdate
Clarityoflayout
Access/Publishing
Versioncontrol
MSWord Good Manualorlinkedfields
Manual Userdefined Uploadindividually,openinWord
NeedstobemaintainedbyuserLinked
MSExcel Canbecumbersome(celllayout)
Manualorlinkedcells
Manual Userdefined Uploadindividually,openinExcel
NeedstobemaintainedbyuserLinked
HTML Needspecialeditor,ordirecthtml
Via scripting Via scripting, Userdefined Via scripting,displaysaswebsite(sharepoint)
Needstobemaintainedbyuser
Radimetricsprotocoleditor
Good Automated(depends onCTmanfr)/Manual
Manual Notuseradjustable,poorlayout
Exporttopdfanduploadindividually
Tracksprotocolversion
CTProtocolMonitoringandOptimization
• Joint Commission Standard PC.01.03.01: The [critical access] hospital plans the patient’s care.
A 26. Diagnostic computed tomography (CT) imaging protocols are reviewed and kept current with input from an interpreting radiologist, medical physicist, and lead imaging technologist to make certain that they adhere to current standards of practice and account for changes in CT imaging equipment. These reviews are conducted at time frames identified by the [critical access] hospital.
A 25. The [critical access] hospital establishes or adopts diagnostic computed tomography (CT) imaging protocols based on current standards of practice, which address key criteria including clinical indication, contrast administration, age (to indicate whether the patient is pediatric or an adult), patient size and body habitus, and the expected radiation dose index range.
CTdosemonitoring
• Order?Protocol?StudyDescription?Examcard?
• Terminologyisnotdefined.Becarefulwhencommunicating.
Understandyourworkflow
Referringphysicianordersstudy
CTCHESTW
Radiologyresidentreviewsorderandclinicalhistory,selectsscanprotocol
• Standardcontrast-enhancedchest• Interstitiallungdisease• …
Technologistchoosessize-specificprotocol,ormayadjusttechniqueforpatientsize
• StandardChest• Interstitiallungdisease• …
instructureddosereport“order”,”studydescription”
”protocol”,“examcard”retrievedfromimages
visibleonERMonly“protocolling”
->requiresimagestobesenttomonitoringsoftware
Dosereporting
• Bystudydescription/order– Imagingprotocolnotknown– Notasusefulforscanparameteroptimization
• Byscanprotocol– Sameimagingprotocolmaybeusedfordifferentorders
• DIR:byorder
CTdosemonitoring
Wherehaveallthestudiesgone..
UnderstandyourIT:Whatgetssendwhere?
CTexamiscompletedonscanner
Technologistsendsstudy
DirectlytoPACS
“Smartrouter”
KnowstosendCTstudytoradimetrics
CTexamiscompletedonscanner
Autosend toradimetrics
Initialsetup:
Newsetup:
ITneedstobepartoftheequation
CTexamiscompletedonscanner
Autosend toradimetrics
Newsetup:
Drawback:Thislinkcanbreakeasily
Finalwords
• Establishingprotocol/dosemonitoringisnottrivial• Administrationsupport(dedicatedtechnologists’timecosts$$)• Knowyoursystems,yourworkflow
• BuildaDEDICATEDteam– Needtobeonthesamepagewithtechnologists/radiologists– GetsomeonefromITwhoCANHELP
• Knowyourmedicalphysicscolleagues,reachouttosomeonewithsimilarenvironment
Acknowledgements:UChicago CTmanagerandtechnologists,ITgroup,MedicalPhysicsGroup,NickBevins,PhD