RealWorldExperience:DevelopingDoseandProtocolMonitoring

fromScratch

IngridReiser,PhDDABRDepartmentofRadiologyTheUniversityofChicago

Outline

• CTprotocolmonitoring– Let’sbuildaprotocolbook!

• CTdosemonitoring

Fromscratch:statusasof~2015

• Fleetof8-9PhilipsCTscanners,mixofinpatient,outpatient,dedicatedpediatric• Radimetrics installed,about60%ofCTstudiesrecorded

• Events:– Majorsoftwareupgradeonsomescanners(PhilipsiPatient)– 3scannersreplaced,whichaddedGE– Openingofremotefacility

• Personneltransitions(CTmanager)• NodedicatedCTphysicist

CTProtocolMonitoringandOptimization

• Joint Commission Standard PC.01.03.01: The [critical access] hospital plans the patient’s care. A 25. The [critical access] hospital establishes or adopts diagnostic computed tomography (CT) imaging protocols based on current standards of practice, which address key criteria including clinical indication, contrast administration, age (to indicate whether the patient is pediatric or an adult), patient size and body habitus, and the expected radiation dose index range.A 26. 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 [critical access] hospital.

JCrequirements

• CTQualityPolicywasestablished– CTQualityCoreTeamcreated,taskedwithprotocolanddosereview

Theprotocols

“Routine critical and systematic review of protocols are necessary not only to ensure that appropriate radiation dose levels are being used but also to verify that other aspects of are

acceptable and consistent with best practice standards.”

Protocolreview:Whatare ourprotocols?

Whataretheparameters?

J Am Coll Radiol 2014;11:267-270.

Theprotocols

“Routine critical and systematic review of protocols are necessary not only to ensure that appropriate radiation dose levels are being used but also to verify that other aspects of are

acceptable and consistent with best practice standards.”

– Typically>200imagingprotocolsperscanner– NeedtheactualCTprotocols

Theprotocols

“Routine critical and systematic review of protocols are necessary not only to ensure that appropriate radiation dose levels are being used but also to verify that other aspects of are

acceptable and consistent with best practice standards.”

– Typically>200protocolsperscanner– NeedtheactualCTprotocols– Notallvendors/modelsproduceaCOMPLETEhumanreadablelistingofprotocolparameters

Oursolution:gettingscannerprotocols

• Haveserviceengineerretrieveprotocolbackupfiles(Philips)• PhilipsiPatient softwareproducesatext-file(htmlformat)• GERevolutionCTseriesproducecsvfiles– incomplete

• noserieslabels• RevolutionCT:Nopitchfactor,protocolnumberingomitted

Usingtheprotocols(i.e.,reviewlogistics)

• Textprotocolformattingmaynotbeamenableforreview

• Radimetrics hasaprotocoleditor– Mayormaynotimportyourprotocolparameters

• Oursolution:– Parseprotocolsusingascriptinglanguage(python,matlab,etc)– Generateexcelmasterprotocolforeachscanner

Acquisitionparameters

Reconstructionparameters

Multiplevendors:Consistencyofprotocols

• Perfectparametermatchnotalwayspossible– GE:3.75mmsliceinterval– Philips:4mmsliceinterval

Currentbestpracticestandards?Acceptable

doselevels?

Radiologistsinindividualsections:

Physicist: Technologist/Radiologist:

protocolsparameters

Scaninstructions Consolidation,

Standardization

Notificationvalues Review:

appropriatedoseandimagequality

Approvalofprotocols

Theteam

“Protocol review and improvement efforts should be undertaken by a core team consisting of at least one radiologist, one physicist, and one technologist.”

• Radiologistcanonlyoverseeprotocolsrelevanttotheirsection– GenerallycannotapproveCTprotocolsforadifferentsection(i.e.,thoracicradiologistcannotapproveneuroprotocols)

J Am Coll Radiol 2014;11:267-270.

Theteam

“Protocol review and improvement efforts should be undertaken by a core team consisting of at least one radiologist, one physicist, and one technologist.”

• CTclinicalmanager(s)overseesCT– IsultimatelyresponsibleforthequalityofCTscansperformedbyhis/hertechnologists

– Has/shouldhaveaninterestinwelldocumented,standardizedCTimagingprotocols

– Supervisesandcommunicateswithalltechnologists• Hasfirepower

Theteam

“Protocol review and improvement efforts should be undertaken by a core team consisting of at least one radiologist, one physicist, and one technologist.”

• CTclinicalmanager(s)overseesCT– Cangetaccesstoscanners(masteroftheschedule)– Knowstheprotocols– ControlshowCTscannersaresetup(i.e.,passwordprotectionofprotocoleditor)

..DOpasswordprotectyourCTprotocols- allchangesaremadeinthebestintent..

Must-haves:

• Supportfromtheadministration:– Dedicated,protectedtechnologists’time($$)

• CTmanagersupportcritical– Appointsonededicatedtechnologist(“technicalcoordinator”)– Scheduling:protectedtimeOFFTHEFLOORtohelpwithprotocols

• Difficultiftherearestaffingshortages

– ControlsCTschedule(blockscannertimeforprotocolupdates,notificationsettings)

• Leadtechnologistmaynotbeideal,astheyalreadyhavemanyotherresponsibilities

Aprotocolbook

• Protocolbook:– Scaninstructions:Technologist/radiologist– Scanparameters:Physicist

• Protocolbookhelpsestablishstandard– Technologists’willchangescanparametersontheflybecauseA radiologistrequestedscanA tobedoneinacertainway..

Ourapproachtobuildingaprotocolbook

• Goal:Buildaprotocolbookthatisflexible,editable,allowingforautomatedupdatingofscanparameters

• Requirements:– Easyexchangewithtechnologists/clinicians(MSoffice)– Automatedscanparameterupdate

• Todisseminate:– UtilizeMSsharepoint

• Use.aspx extensiontodisplayhtml

Softwaretool

Data entry:clinicalinstructions

Data entry:scanparameters

Data entry:Scanparameterupdate

Clarityoflayout

Access/Publishing

Versioncontrol

MSWord Good Manualorlinkedfields

Manual Userdefined Uploadindividually,openinWord

NeedstobemaintainedbyuserLinked

MSExcel Canbecumbersome(celllayout)

Manualorlinkedcells

Manual Userdefined Uploadindividually,openinExcel

NeedstobemaintainedbyuserLinked

HTML Needspecialeditor,ordirecthtml

Via scripting Via scripting, Userdefined Via scripting,displaysaswebsite(sharepoint)

Needstobemaintainedbyuser

Radimetricsprotocoleditor

Good Automated(depends onCTmanfr)/Manual

Manual Notuseradjustable,poorlayout

Exporttopdfanduploadindividually

Tracksprotocolversion

CTProtocolMonitoringandOptimization

• Joint Commission Standard PC.01.03.01: The [critical access] hospital plans the patient’s care.

A 26. 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 [critical access] hospital.

A 25. The [critical access] hospital establishes or adopts diagnostic computed tomography (CT) imaging protocols based on current standards of practice, which address key criteria including clinical indication, contrast administration, age (to indicate whether the patient is pediatric or an adult), patient size and body habitus, and the expected radiation dose index range.

CTdosemonitoring

• Order?Protocol?StudyDescription?Examcard?

• Terminologyisnotdefined.Becarefulwhencommunicating.

Understandyourworkflow

Referringphysicianordersstudy

CTCHESTW

Radiologyresidentreviewsorderandclinicalhistory,selectsscanprotocol

• Standardcontrast-enhancedchest• Interstitiallungdisease• …

Technologistchoosessize-specificprotocol,ormayadjusttechniqueforpatientsize

• StandardChest• Interstitiallungdisease• …

instructureddosereport“order”,”studydescription”

”protocol”,“examcard”retrievedfromimages

visibleonERMonly“protocolling”

->requiresimagestobesenttomonitoringsoftware

Dosereporting

• Bystudydescription/order– Imagingprotocolnotknown– Notasusefulforscanparameteroptimization

• Byscanprotocol– Sameimagingprotocolmaybeusedfordifferentorders

• DIR:byorder

CTdosemonitoring

Wherehaveallthestudiesgone..

UnderstandyourIT:Whatgetssendwhere?

CTexamiscompletedonscanner

Technologistsendsstudy

DirectlytoPACS

“Smartrouter”

KnowstosendCTstudytoradimetrics

CTexamiscompletedonscanner

Autosend toradimetrics

Initialsetup:

Newsetup:

ITneedstobepartoftheequation

CTexamiscompletedonscanner

Autosend toradimetrics

Newsetup:

Drawback:Thislinkcanbreakeasily

Finalwords

• Establishingprotocol/dosemonitoringisnottrivial• Administrationsupport(dedicatedtechnologists’timecosts$$)• Knowyoursystems,yourworkflow

• BuildaDEDICATEDteam– Needtobeonthesamepagewithtechnologists/radiologists– GetsomeonefromITwhoCANHELP

• Knowyourmedicalphysicscolleagues,reachouttosomeonewithsimilarenvironment

Acknowledgements:UChicago CTmanagerandtechnologists,ITgroup,MedicalPhysicsGroup,NickBevins,PhD