Methods:
According to principles of Image Gently® [4,9],
Choosing Wisely® [6] protocols and ACR Appropriateness Criteria® [3],
this project applies instruments of communication for recommendation and guidelines for exams indication and information to paediatricians,
health professional support and patients.
Also one of the strategies was to share the decision with the parents about radiological tests requested to the children,
to raise awareness in order to avoid unnecessary testing and the cumulative effect of ionizing radiation [6].
Based on the principle “as low as reasonably achievable” and Image Gently® [6],
this study stimulated the use of alternative methods like ultrasound and magnetic resonance,
when possible,
gave explanation of the application of a patient’s wallet to aware the parents and control exams,
and some folders to give information about ionizing radiations effects to parents and paediatricians.
Radioprotection Wallet for children under 12 years,
was distributed as a tool for parents and doctors to control children's exposure to radiation,
following Image Gently® card [4] and a previous project in Brazil [10,11].
The parents were responsible for keeping this wallet and take it in the consultations to avoid repetition of exams already done.
The campaign followed the recommendations from the American College of Radiology [3] and The Society for Pediatric Radiology [4,9] for low dose examinations.
The project performed reduce dose CT and X- Ray’s protocols according to age and weight using the lowest dose of radiation and limitation of the exam radiation area,
avoiding multiple phases and CT sequences,
and starting the examination after correct positioning of the patient [4,9].
The project also applied instructions about workflow and check management from the initiation of the clinical request to the time patients enters the room for the examinations based on Image Gently® [4],
Eurosafe Imaging® workflow [5] and Brazilian College of Radiology Quality Program [12].
The quality of the exams was supported by a certificated medical physicist. The review of the protocols of the exams was made in accordance with the radiologists of the institution.
Questionnaires for the participants were performed to evaluate the radioprotection knowledge the campaign and was reinforced and disseminated by a distance education learning.
The project used the Kotter's 8-Step Change Management Methodology [13] to organize the implementation.
Results: Actions are taken:
Based on the Kotter’s 8 step process to successful changes,
it was implemented the following (Figure 1):
Fig. 1: Figure 1: Kotter's 8-Step Change Management Methodology
References: Reference: Based on Kotter's 8-Step Change Management Methodology. Hospital Santa Lucinda, Pontifical University Catholic of São Paulo, Sorocaba – São Paulo/ Brazil.
1) Established a sense of urgency: radioprotection was elected as the central issue to be implemented according to the Brazilian regulations [7,14],
international campaigns [3-8] and a previous project in Brazil [10,11].
2) Build an administrative coalition: commitment of the Clinical and Technical Directors of the hospital (Stakeholders);
3) Form: Developed a vision and strategy
3.1 Hospital committee of Radioprotection- Objective: Implementation,
maintenance and evaluation of the radioprotection program,
supported by a multi-professional team,
committed to change the daily practice by working together with radiologists,
radiographers,
medical physicist,
referring doctors and parents to use only the necessary radiation dose,
especially in children (Table 1 e 2).
Table 1: Table 1: Members of the Hospital Committee Radioprotection (Radiology Team)
References: Reference: Hospital Santa Lucinda, Pontifical University Catholic of São Paulo, Sorocaba – São Paulo/ Brazil.
Table 2: Table 2: Members of the Hospital Committee Radioprotection (Health Professionals)
Reference: Hospital Santa Lucinda, Pontifical University Catholic of São Paulo, Sorocaba – São Paulo/ Brazil.
References: Reference: Hospital Santa Lucinda, Pontifical University Catholic of São Paulo, Sorocaba – São Paulo/ Brazil.
3.2 Internal regulations document: specification of the criteria,
actions,
controls based on The Brazilian Health Surveillance and Health Ministry Ordinance (SVS/MS 453/98) [15],
the Certification Program for Teaching Hospitals (MS/MEC 285/15) [14] were done by a regiment for orientation to the radioprotection program enrolling: justification of the exams,
auditory control,
equipment calibration,
professional protective,
and permanent education.
3.3 Radiation dose reduction with quality maintained:
A guideline book containing instructions based on Image Gently® [4,9,16,17] and ACR Appropriateness Criteria® [3],
International Atomic Energy Agency recommendations [8] and Eurosafe Imaging® workflow [5] were applied,
controlled by a certified and qualified medical physicist from Brazilian Association of Medical Physicist.
We implemented plumbic protection to the children beds in CUI and a distance of 140 cm to the next neighborhood bed to decreases radiation,
done by a medical physicist.
3.4 Patient and multidisciplinary team awareness of radiation’s effects and benefits:
For the children from paediatric section and CIU who realized radiologic exams received a radioprotection wallet (total 500 patient’s radioprotection wallet were distributed in the hospital from 2017 to 2018) (Figure 2).
Fig. 2: Figure 2: Pediatric Radioprotection Wallet
References: Reference: Based on Image Gently Card. Hospital Santa Lucinda, Pontifical University Catholic of São Paulo, Sorocaba – São Paulo/ Brazil.
4) Communicated the vision of change:
Dissemination of campaign support material (radiological exams data reports,
guidelines booklet for parents and paediatricians,
online information) were performed based on Image Gently® and Paediatric Society of Sao Paulo [18] standard done by the Hospital Committee were disseminated to the hospital.
5) Invested employee’s empowerment - radiologists,
nursing,
administrative and physicians;
Support regular education meetings in person were held for the hospitals: health professionals,
nurses,
paediatricians,
radiologists,
receptionists,
radiology technicians,
reception staff different work periods with the engagement of radiology residents.
6) Demonstrated achieved short-term achievements – equipment’s calibration,
paediatricians’ guidelines,
conscientious patients and dose reduction of ionizing exams and pilot neonatal results;
7) Sustain the acceleration change to be a reality: permanent education,
bimonthly meetings,
and perseverance of the committee's deliberations;
We applied questionnaires to health professional team and medical students (n=123). The questionnaires were applied to 9% for paediatricians,
6% radiologists,
14% members of the radiation protection commission,
27% nurses,
and administration managers,
14% radiology technicians and 30% medical students and residents (Figure 3).
Fig. 3: Figure 3: Percentage of Health Professionals and Medical Students the participated of Radioprotection Program.
References: Reference: Hospital Santa Lucinda, Pontifical University Catholic of São Paulo, Sorocaba – São Paulo/ Brazil.
It was noticed from the results that the professionals who work directly with the radiology service (radiologists and radiology technicians),
showed to be familiarity with the campaign,
but other nurses and medical students did not know the radioprotection program appropriately (Figure 4 and 5).
Fig. 4: Figure 4A: Percentage of the use of the reduced radiation dose of the protocols for adults according to the radiologists and radiographers
References: Reference: Hospital Santa Lucinda, Pontifical University Catholic of São Paulo, Sorocaba – São Paulo/ Brazil.
Fig. 5: Figure 4B: Percentage of communication on previous radiographic exams prior to the completion of the new examination
References: Reference: Hospital Santa Lucinda, Pontifical University Catholic of São Paulo, Sorocaba – São Paulo/ Brazil.
The campaign was well accepted by the participants and parents. Dissemination of the radioprotection campaigns and the training system can be a useful tool to improve the knowledge about the campaign principles.
The campaign has been incorporated in routine hospital professional’s activity,
although more interventional education must be done,
to awareness the radioprotection program appropriately especially to health professionals and medical students.
8) Establishment mentality change - involvement of the academic community.
The professional team can have access to the documents,
meeting schedules and action plans of the Radiological Protection Committee through access on the teaching hospital website [19].
The project introduced the radioprotection theme in the radiology pedagogic area to medical students; internal medicine,
paediatric,
surgery and radiology residents in multidisciplinary meetings in the University.
A distance education platform has been developed for the academic community and health professionals about radioprotection and questionnaires for undergraduate medical students,
residents,
nurses,
reception hospital managers and paediatricians based on Image Gently® [4],
Choosing Wisely® protocols [6],
ACR Appropriateness Criteria® [3],
and Eurosafe imaging® [5].
The perceptive is that the virtual education program will be applied to all the hospital health professionals,
fourth and senior medical students,
residents and doctors; distribution of the radioprotection wallet in the nursery together with the vaccination card; and the study will apply the virtual education program to all the hospital health professionals and voluntary doctors; and extend the campaign to others sections of the hospital.