Institution
As the largest provider of health services in Turkey,
the Ministry of Health is segmented into multiple hospital associations including the 2ndHealthcare Region of Istanbul Province (a.k.a. Anatolia North, which consists of 13 hospitals and 6 dental hospitals/centers.
In Anatolia North 3 million residents are being served; 11.1 millions outpatient admissions and 250 thousands surgical operations are being performed annually.
The annual number of radiologic procedures in Anatolia North are more than 4 milion and roughly represents 1/1.000th of world radiological services.
Sancaktepe is a mid-size (400 beds) receiver hospital ( Fig. 3 ).
It was established at the end of 2017,
as a part of Health Sciences University Istanbul Fatih Sultan Mehmet Education and Research Hospital (FSM) -a EuroSafe Imaging Star (*****) regional dose excellence center, and has functioned for several months under until it became fully autonomous. Annual number of CT examinations in Sancaktepe has exceeded 66.905 in 2018..
Sancaktepe has enjoyed all benefits of being a part of FSM where a comprehensive dose management system was implemented,
and modern dose surveillance IT applications were used.
As FSM was designed to comply with highest standards and provide a framework to assist other centers develop the required dose management infrastructures according to relevant IAEA guidelines (5),
Sancaktepe hasd uplicated its quality assurance practices.
The compliance of the facility with the established criteria was verified through a process of systematic and critical analysis of the quality of radiological services and with dose optimization results shown below.
Dose Management Strategy
Methods used to implement the diagnostic reference levels,
to inform and train the medical staff were initially a part of a larger pan-European project (i.e. Affidea Dose Excellence Campaign) to implement a uniform dose management strategy in different centers with different machines across entirely different countries.
The project’s goals were as follows:
· Transform dose awareness from an act to a habit
· Educate personnel
· Justify high dose examinations
· Standardize protocols and practices
· Optimize protocols and practices
· Communicate message to stakeholders
· Promote best practices and be safe
Sancaktepe had many of the necessary infrasturucture and proceses to meet that strategy according to relevant IAEA guidelines (5) outlined in Figure 1.
Dose Data Acquisition and Tracking
For current dose levels,
data set was from 01.01.2018 to 17.12.2018.
In that period ,
66.905 individual standartized sequences covering wide range of clinical indications were available to analysis.
The sequences were acquired using 16-slices scanner.
Sancaktepe was designed as a dose excellence center from the very beginning,
and adopted Anatolia North’s standartized and optimized CT protocols.
Therefore,
pre/post optimization comparisons were not available.
Instead,
the local DLPs were compared with DLPs of the Umraniye Numune Training and Research Hospital,
another Anatolia North hospital that was classified as EuroSafe Imaging Star (*****).
That hospital was specifically selected as it had a 16 slices scanner of same model and production year.
For the purpose of dose data acquisition and analysis,
a commercial software (Dosewatch,
GEHC) was used.
This web-based solution captures,tracks and reports radiation dose directly from the medical devices.
It monitors and analyzes high dose alerts and patient cumulative dose,
includes quality metrics to assess the technical factors,
has data consolidation and statistical analysis tools for protocol optimization and dose reduction by optimizing dose levels.
For comparative evaluations we have used unified pan-European DRLs of our CT service provider,
Affidea.
These DRLs were determined afer median DRLs published from several European countries (Switzerland,
Belgium,
Finland,
Norway,
France,
Germany,
Poland,
UK) from 2010 onwards (2).
Dose Optimization Achievements
Median doses at both hospitals were statistically same (p<0.05) for the majority of the protocols. To give an example,
median doses for abdomen-pelvis protocol were 293 mGy.cm,
at both institutuions. This value was much lower (-277 mGy.cm) than respective unified pan-European DRL of 570 mGy.cm. ( Fig. 4 ). Median doses for lumbar spine protocol were 231 mGy.cm and 222 mGy.cm at Sancaktepe and Umraniye,
respectively.
These values were much lower than respective unified pan-European DRL of 270 mGy.cm with a distance between -40 to -49 mGy.cm ( Fig. 5 ).
Sancaktepe,
as a new hospital,
had reached even lower doses in certain CT examinations.
As an example, median dose for thorax protocol were 449 mGy.cm and 643 mGy.cm at Sancaktepe and Umraniye,
respectively.
Sancaktepe’s median DLP was slightly lower than respective unified pan-European DRL of 460 mGy.cm with a distance of -12 mGy.cm.
On contrary,
Umraniye’s median DLP was significantly higher than respective unified pan-European with a distance of -180 mGy.cm ( Fig. 6 ).