In the period from 2011 to 2014, a pioneer pilot radioprotection project was applied in a private health care system covering 140000 people in Sorocaba,
Sao Paulo,
Brazil [7,8] (Figure 1; Table 1):
- 17 thousand personal wallets were given to children from 0 to 12 years old.
- Reduction of 22 percentages of RX and CT radiologic exams in paediatric emergency room.
- Reduction of 29 % in the solicitation of 2 or more RX for the same child.
- Dissemination of local communication networks.
- Positive point on Hospital Certification (Joint Commission International Quality System).
Fig. 1: Figure 1: Percentage of visits that generated radiological examinations performed in the paediatric emergency section of a supplementary health system in the interior of São Paulo State before and after the Radioprotection Campaign for children up to 12 years old.
References: Reference: Bernardo MO et al. (2017) Campanha e carteira de radioproteção: estratégias educativas que reduzem a exposição excessiva de crianças a exames radiológicos. Rev Paul Pediatr. 2017;35(2):178-84. (Author Master thesis).
Table 1: Table 1: Most frequently requested radiological examinations in the pediatric emergency sector according to the period evaluated.
References: Reference: Bernardo MO et al. (2017) Campanha e carteira de radioproteção: estratégias educativas que reduzem a exposição excessiva de crianças a exames radiológicos. Rev Paul Pediatr. 2017;35(2):178-84. (Author Master thesis).
As the pioneer project was successful [7,8],
it was disseminated to a National Health Care System covering 2,7 million people,
in the period from 2016 to 2018.
Objectives: To propagate the information about excessive exposure due to radiological exams.
To evaluate the radioprotection campaign in development in the Unit Care in Brazil,
to analyze the results of an initiative aimed at improving the reasonable use of radiological examinations performed in children assisted in the emergency and outpatient services at the units that joined the campaign.
Methodology: The study was approved by the Research Ethics Committee of the School of Medicine University in Sorocaba-Sao Paulo / Brazil.
CAAE 68956317.2.0000.5373.
All the procedures of the study were carried out in accordance with the applicable ethical precepts.
The instruments were developed by the National Health Care with the orientation of the authors.
Analyse of the data were done by professors of the University in Sorocaba-Sao Paulo / Brazil.
We used the 8 steps of Kotter’s change management model to organize the implementation [12].
We implemented a Radioprotection Campaign to this National Health Care and local units according to Image Gently® [1-3,13] and ACR Appropriateness Criteria ® [4] ensuring the lowest dose of radiation and quality of exams and applied a Radioprotection Wallet for children under 12 years,
as a tool for parents and doctors to control children's exposure to radiation,
and a distance educational learning.
We also applied instruments and videos of communication to parents and paediatricians about the risks,
benefits,
patient safety and recommendations in rational use of radiologic exams and patient safety [14] based on Image Gently® [1-3],
ACR Appropriateness Criteria® [4] and International Atomic Energy Agency [15] (Figure 2).
Fig. 2: Figure 2: Paediatric Radioprotection Wallet
References: Reference: Unimed National Health Care (2019) Proteção radiológica infantil [Internet]. [cited 2019 Jan 05]. Available from: http://www2.unimed.coop.br/nacional/br/pri/index.html.
A guideline book containing instructions on how to organize and apply the program in the unit was done based on Image Gently® [1-3] and ACR® criteria [4],
Brazilian College of Radiology [6] and Paediatrician Society of Sao Paulo [16] recommendations.
It was also displaced online and contains information about workflow and checklist to be done before,
during and after de examinations were applied based on Image Gently® [13] and Eurosafe imaging® workflow [17].
The support meetings by videoconference or in person were held for
all hospitals bimonthly.
In these meetings,
we involved multi-professional team: hospital’s managers,
physicist professional,
paediatricians,
radiologists,
receptionists,
nurses,
radiology technicians.
The campaign was well accepted by all professionals,
families,
and patients involved.
The review of protocols of exams was made in accordance to the radiologists of the institution using:
The lowest dose to maintain the quality for the examination report; limiting the exposure area and avoid repeated series; start the examination after correct positioning of the patient.
The campaign followed the recommendation of the American College of Radiology [4] and the Society of Pediatric Radiology [2] guidelines.
To assess the effectiveness of these actions,
the number of radiological examinations performed at the paediatric emergency room in a period of one year preceding the campaign was compared with the number of radiological examinations performed one year after the campaign based on unit’s billing database.
Children ́s target was divided into age groups (0 to 4 years old,
5 to 8 years old,
9 to 12 years old).
Findings:
This project included 46 units,
of which 24 had own hospitals and created radiological committees (Figure 3).
Fig. 3: Figure 3 - Campaign workflow
References: Reference: Unimed National Health Care, Brazil (2019). Available from: http://www.unimed.coop.br/nacional/br/.
In the following year,
we observed a 14,2 % reduction of radiological exams performed at paediatric emergency room and 22,6 % in elective section in the units with radioprotection committee in from 2016 to 2017.
There was also 14,6 % reduction in the request of this percentage at the paediatric emergency room in the institution without own hospitals and radioprotection commission and 22,1% reduction at the elective attendance (Table 2).
Table 2: Table 2 - Percentage of paediatric attendance with radiological exams
References: Reference: Project elaborated by Pontifical University Catholic of São Paulo and Unimed National Health Care, Brazil
It reinforced that communication is very important to change a culture and promote good practice in medicine if regular meetings and support education are done with a stakeholder (leadership).
The radioprotection commissions were effective to organize information data.
There were higher values of the ratio of exams for care in the Urgency and Emergency sections in relation to the Elective,
Outpatient and Clinic sections.
Also,
there was a high percentage of exams (paranasal) in the age 0-4 group (8.1% in the Emergency and 5.4% in the elective,
in 2017),
not following International Guidelines for radiographic and tomography indications [4,18] (Figure 4).
Fig. 4: Figure 4 – Type of exams percentages by age range for emergency and outpatients
References: Reference: Project elaborated by Pontifical University Catholic of São Paulo and Unimed National Health Care, Brazil
The probable reasons are the shorter diagnostic time when it comes to Urgency and Emergency; pressure due to parents' insecurity;
doctors defensive clinical practice;
no easy access to patient’s medical record; lack of guidelines adherence.
In 2018 the project stimulated the origin of a radioprotection implementation guideline and a clinical decision recommendation that is giving support to other hospitals,
including universities interested.
It also gave origin to a distance education learning.
In 2019 we are going to reinforce and analyze the effects of the permanent education and dose level rate in the units been support by a physics professional team.