Action3: Implement measures to maintain radiation doses within diagnostic reference levels (DRLs)
The currency of the Image Gently Alliance is information and knowledge and developing methods for disseminating this information. The Alliance does not have a vested regulatory authority,
is not predominately research-based,
does not have industry oversight,
and has no accreditation responsibilities.
However,
the Alliance has grown to be an acknowledged influence on and respected collaborator for those US organizations with these responsibilities.
Over the years,
these organizations have included:
- The Joint Commission (TJC)
- Centers for Medicare and Medicaid Services (CMS)
- Food and Drug Administration (FDA)
- Environmental Protection Agency (EPA)
Strategies for improved use of diagnostic imaging in children include improved,
relevant equipment design,
appropriate justification,
and improved acquisition techniques (i.e.,
protocols) to be used during imaging of children.
Incumbent on this last point however is an understanding of the target ranges of both image quality and dose (or dose estimate).
DRLs address this need [5-7].
DRLs are not well established and their use is not currently required in the US.
However,
there is growing recognition of this concept as a guide in diagnostic imaging [7] in addition to other actions in which the Image Gently Alliance has participated.
Encouraging adherence to standards for performance include:
1. The Joint Commission (TJC) Diagnostic Imaging Requirements (July 2015).
“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 organization.” Page 6 (Figure 4)
http://www.jointcommission.org/diagnostic_imaging_standards/
a. “Radiation dose optimization techniques and tools for pediatric and adult patients addressed in the Image Gently® and Image Wisely® campaigns
2. Centers for Medicare & Medicaid Services (CMS): Updated Guidance for Hospital Services: “Incorporation of the “As Low as Reasonably Achievable” (ALARA) principle of medical imaging,
which optimizes image quality while minimizing radiation exposure in accordance with nationally recognized guidelines” Page 2
https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions-Items/Survey-and-Cert-Letter-15-38.html
a. “Professionally approved standards also include the recommendations or guidelines promulgated by expert governmental agencies,
such as the US Food and Drug Administration,
as well as those issued by nationally recognized professional organizations,
such as the American Medical Association,
American College of Radiology,
Radiological Society of North America,
The Alliance for Radiation Safety in Pediatric Imaging, American Society of Radiologic Technologists,
the American College of Cardiology,
the American College of Neurology,
the American College of Physicians,
etc.”
3. The Food and Drug Administration (FDA): Discussed DRLs in US
http://www.fda.gov/Radiation-EmittingProducts/RadiationSafety/RadiationDoseReduction/ucm2007191.htm
a. “Some steps have been taken to address [factors contributing to unnecessary radiation exposure].
Through its Image Gently and Step Lightly campaigns,
the Alliance for Radiation Safety in Pediatric Imaging has developed educational materials for pediatricians,
radiologists,
radiologic technicians,
and parents to encourage careful use of CT and interventional fluoroscopy with children. These campaigns are designed to increase awareness of ways to reduce radiation dose in pediatric imaging procedures.”
4. The Environmental Protection Agency (EPA). Interagency Working Group on Medical Imaging included three individuals from the Image Gently Steering Committee (Goske - Alliance Chair,
Don and Applegate)
http://www.epa.gov/radiation/federal-guidance-report-no-14-radiation-protection-guidance-diagnostic-and-interventional
a. “Professional societies provide excellent guidance on imaging,
such as the ‘Image Gently’ campaign” Page 59
5. Other Content
a. PiDRL
i. The Image Gently Alliance formally reviewed the ESR pediatric Diagnostic Reference Level (PiDRL) 2015-16 document in preparation
b. AAPM
i. Keith Strauss and Marilyn Goske served on AAPM committee [The Alliance for Quality Computed Tomography (AQCT)] for development of pediatric head CT protocols.
http://www.aapm.org/pubs/CTProtocols/
c. Keith Strauss developed age based protocols for head and body CT on Image Gently website http://www.imagegently.org/Procedures/Interventional-Radiology/Protocols
d. Keith Strauss worked with members of the Interventional Fluoroscopy Committee of the Medical Imaging and Technology Alliance (MITA) to improve the application of new diagnostic imaging equipment during pediatric imaging. This collaboration resulted in “Essential Question for Consideration in the Design of Interventional X-ray Equipment Intended for Pediatric use.” http://www.medicalimaging.org/ publications-and-research/essential questions
e. Image Gently Organized ALARA conferences
f. Nuclear Medicine Guidelines (“Go with the Guidelines”).
Ted Treves [8],
Alliance Steering Committee member,
is a principle author,
and committee lead.
(Figure 5)
6. American College of Radiology (ACR) CT Accreditation: “Image Gently® supporter logo indicates a facility accredited in pediatric CT imaging.
Such facilities commit to imaging pediatric patients with appropriate radiation dose.” (Figure 6) http://www.acraccreditation.org/~/media/Documents/CT/CT-Accreditation-Testing-Instructions-72715-final.pdf?la=en
7. ACR Dose Index Registry: Alliance Steering Committee members are part of the registry committee (Goske,
Frush)
a. CT http://www.acr.org/Quality-Safety/National-Radiology-Data-Registry/Dose-Index-Registry
Action 10: Improve communication with health professionals through EuroSafe Imaging Steering Committee,
website,
newsletters,
conferences,
training materials,
and social media
Action 11: Improve information for and communication with patients regarding radiological procedures and related risks in order to ensure empowerment of patients
EuroSafe Action items 10 and 11 are closely linked in principle and resonate with a recent summary of the Image Gently Alliance [2].
“As previously discussed,
the formation of the Image Gently Alliance was based on careful consideration of what was originally an implied set of principles (in essence a constitution) which has been consistently adhered to; the success of the organization can easily be defended as due in large part this constitution.
In developing this constitution,
the values of the IG Alliance were safety,
effectiveness,
consensus,
advocacy,
and accessibility. The goals of these values are to have IG be strong,
stable and strategic.
To accomplish these values,
the blueprint was based on the following fundamental elements: the message,
the messengers,
and the messaging.”
The overall message (Gentle,
Wise and Safe),
the messengers,
and messaging are harmonious for these organizations,
a Shared Voice.
Each organization then adapts these fundamental elements based on the specific objectives [i.e.,
“…measures to maintain radiation doses within diagnostic reference levels…) and the landscape of their communities— including medical,
scientific,
patient,
and public.