From media target to model for pediatric dose reduction

The pediatric radiology department at the State University of New York (SUNY) Downstate Medical Center in Brooklyn took a hit in the media following a 2011 New York Times article exposing the facility’s over-radiation of infants through the use of “babygrams.” Now, after implementing a major process improvement plan, the hospital represents a success story for boosting patient safety, according to an article published online June 14 in the Journal of the American College of Radiology.

“Although it was initially motivated by negative media attention, the plan has become a model for other hospitals,” wrote David S. Dinhofer, MD, of the department of radiology at SUNY Downstate Medical Center.

Prior to the process overhaul, a number of factors led to potential over-radiation at the hospital, explained Dinhofer. Almost all babies in the Neonatal Intensive Care Unit (NICU) had their legs, pelvis, abdomen, chest and head included on portable x-rays no matter which body part was originally intended for imaging. Neonatologists would often give verbal orders for studies, and x-ray technologists would conduct these full baby images, or babygrams, assuming that was the preference of neonatologists. Gonadal shielding was also not a hospital policy for NICU patients.

After a review—which involved hospital administration and members of the departments of radiology, neonatology and pediatrics as well as nursing staff—a four-point plan was created:

• Specific written imaging orders must be provided by neonatologists.
• Tighter limits were added to collimation guidelines, and lead collimation lines had to be visible on the image.
• Lead shielding was added to the hospital policy for all chest exposures and gonadal shielding was added for male infants when abdominal films were obtained. Gonadal shielding was not used for female infants, although bismuth shields that provide some reduction in radiation exposure are to be considered.
• S values of image exposure were to be monitored on the portable equipment, and all portable machines were calibrated to preset standards by the pediatric radiologists and medical physicist.

Compliance with the plan was assessed monthly by the hospital’s Radiation Safety Committee and the Radiology Process Improvement Committee, and the results showed improvement, according to Dinhofer. Adherence to the collimation policy immediately reached over 90 percent, and at three months neared 100 percent compliance. Lead apron or shielding was used appropriately in 99 percent of cases within three months.

Dinhofer wrote that the project demonstrated the benefit of teamwork and administrative support. “Each radiologist should make time to be more active in the department and work more closely with the technical staff to find ways to improve quality and diminish errors,” he wrote. “Teamwork does not end in the department.”