Activity 1 – Implementing radiation protection issues in structured referral forms for imaging:
With ESRiGuide (http://www.eurosafeimaging.org/information-for-referring-professionals-2/clinical-decision-support), a tremendous success has been achieved by developing and adopting appropriateness criteria and by implementing them with a computerized decision support tool. The aim of this project is to develop recommendations for optimizing the referral process in a way that all requirements of the BSS Directive (2013/59/Euratom) are fulfilled and that the referral process is more standardized with options for the personalization of the referral (Table 1).
The work bases on the EuroSafe Imaging concept of indication-driven image investigations and relevant ESR publictions (Summary of the proceedings of the international forum 2016: Imaging referral guidelines and clinical decision support - how can radiologists implement imaging referral guidelines in clinical routine, Summary of the European Directive 2013/59/Euratom: essentials for health professionals in radiology, ESR white paper about “How to manage accidental and unintended exposure in radiology). Additional aspects are, according to IAEA, medical ethics, law, health economics and communication. Specific justification problems for children, CT, screening, pregnancy issues, dental radiology and problems with mobile and portable equipment will be addressed.
Activity 2 – Cumulative dose in patients with chronic diseases:
In March 2019, IAEA held a symposium on the Strengthening the Protection of Patients who Need Multiple Imaging Exams (https://www.iaea.org/newscenter/news/strengthening-the-protection-ofpatients-who-need-multiple-imaging-exams). Publications in the scientific literature had been showing patients getting cumulative effective doses (CED) in the range of 50-500 mSv but it was not known if they are a widespread phenomenon or isolated situations. For bringing this highly relevant topic into the European community of radiologists, a package of activities for the protection of patients needing frequent CT and interventional investigations will be developed and will be done in close collaboration with the EuroSafe imaging initiative (Table 2).
Activity 3 – Radiology reports as instruments for applying and communicating the radiation protection safety culture: With the radiology report, besides the details of image interpretation and the diagnosis, the quality and safety aspects are displayed to the readers. Therefore, the report is an important part of the safety culture in imaging and its usefulness for disseminating the achievements in radiation protection should be explored. The EuroSafe concept of the indication-driven investigation underscores the high demand on implementing the issues of the BSS Directive (2013/59/Euratom) in the radiology report. The next step, indication-driven interpretation will be explored with a specific focus on patient safety and with view on setting alerts, making reports actionable and readable, and on new forms of reports (multimedia, combination with 3D printing and others). In terms of readability, the role of patients as readers, the grammar and spelling (no abbreviations, describing quantitative measures in relation to staging or grading systems and/or in relation to normal values described in brackets, links to relevant guidelines and recommendations, text appropriate for multilingual machine translation, precise use of anatomic terms and imaging biomarkers) should be discussed and considered. The recommendations will be made with view on an easy use in clinical practice and to form a base for improving machine learning and artificial intelligence (AI).
Activity 4 - Toolkit for implementation of referral guidelines in national law of EU member states:
With the implementation of referral criteria in the EU, the responsible health authorities and professional societies are facing similar scenarios. As the appropriateness does not only depend on the pre-test probability of a test, but also on issues of health economy and the traditions in the medical service of a country, the recommendations have to be adopted on a European and a national level. Therefore, it makes sense that the ESR Subcommittee supports the national societies in developing a toolkit for the publication and dissemination of referral criteria. By following the motto of communicating primarily the chances and benefits of imaging in relation to the risks with a holistic and interprofessional approach towards a more enhanced safety culture, the following issues will be included: aspects of the national health care system, strategies for bringing latest research to the point-of-care (with issues of radiation protection especially screening, optimization of the workflow, patient safety, and patient empowerment, non-medical exposures, and justification of new types of practices involving medical exposure in advance before being generally adopted).
Activity 5 – Educational toolkit for medical students about the basics of radiation protection:
According to the white paper on radiation protection by the European Society of Radiology, published in 2011, education and training are compulsory prerequisites for radiation protection in clinical radiology. Medical students are the referring physicians of tomorrow and have been defined as a target group according to article 18 (4) of the BSS. Implementing certain issues of the EuroSafe imaging call for action (Action #1-3, 7-8, 12-13) for them seems to be necessary. Basing on the learning objectives of the curriculum for undergraduate radiological education, published in 2019, a toolkit with learning and teaching material in accordance with the recommendations of the BSS will be developed by the experts of this subcommittee and in close accordance with the responsible ESR Subcommittee on Undergraduate Education and the EuroSafe Imaging initiative.
The goals are to mentor medical students to understand the dose-dependent interactions between rays, waves and magnetic fields with the human tissue, to apply the basic rules of diagnostic reasoning in predefined clinical scenarios, to learn critical thinking with a holistic and interprofessional approach, and to know how to use the basic rules of radiation protection in clinics and research.
Activity 6 – Educational Toolkit for simulating justification:
As a further step, a toolkit for a medical students referral course will be developed with the current working title “Justification: Implementing radiation protection issues in referral schemes for imaging”.
Activity 7 – Definitions in risk communication with adults and children:
In risk communication, an important point is to strengthen on precise and evidence-based definitions, among them the benefit-risk or chance-risk communication rather than on the inaccurate wording of risk-benefit relations, and the use of the term “radiation burden” only for accidents and not for justified exposures.
Activity 8 – Risk communication after nuclear and radiation accidents and incidents to people far away from the accident location:
The aim of this project is to define recommendations for a state-of-the-art communication after radiation-induced accidents or incidents to people far away from the accident location without being exposed to biological effects of ionizing radiation. If such an accident may occur, the community of radiation protection specialists should be well prepared for communicating appropriately the risk in public media and local emergency settings. A concise statement for summarizing the most relevant aspects of risk communication under such circumstances seems necessary. After the Fukushima and Chernobyl disasters, the great majority of the worldwide population was not exposed to the biological (deterministic and stochastic) effects, but rather to the non-biological effects.
Activity 9 – Dose management:
Dose management and the potential provision of a low-cost solution to ESR members to support checking the dose levels and detecting outliers, obtaining dose information with view on diagnostic reference levels and risk assessment.
Activity 10 – DRLs and how they will affect clinical practice:
EUCLID (European Study on Clinical Diagnostic Reference Levels for X-Ray Medical Imaging): Basing on the results of the a workshop on DRLs based on clinical education and following the European Commission Tender project on DRLs.