The University of Wisconsin–Madison has about 300 different CT protocols in routine clinical use, which presents quite the management challenge. Researchers there tackled the issue with a wiki-based tool, and took to the pages of the Journal of the American College of Radiology to explain their strategy.

When factoring in distinct clinical indications, reconstructions and different scanner models, there are 180,000 unique scanner parameters needed to define the institution’s complete CT protocol set, according to lead author Timothy P. Szczykutowicz, PhD, of the departments of radiology, medical physics and biomedical engineering, and colleagues.

“Problems arise when so many protocols and protocol parameters are in clinical use,” the authors wrote. "CT protocols were broken into seven different body sections documented using hundreds of pages of Word documents. Maintaining two different sets of the same protocols, one for each of the two technologist pools at two different locations within our institution, further complicated protocol management."

To address these issues, a robust system for managing CT protocols was needed. The organization moved its Word-based documentation to a wiki-based solution to fully exploit the redundancy—what they call the master protocol concepts 3 and 4.

For example, for the administration of intravenous contrast agent, the routine abdominal-pelvic protocol uses the same contrast injection protocol as UW-Madison’s rule-out hernia protocol, abdominal portion of its chest protocol, the portal phase of its kidney tumor protocol and some others, according to the article. “These protocols all use the P3T Abdomen setting at a flow rate of 3 mL/s. They use the same setting because the clinical question to be answered is similar in all of these protocols. Therefore, instead of listing the details for this setting on each of these protocols, for each scanner these protocols are used on, a reference to a master protocol for this setting is used,” the authors explained. “This allows one to more easily manage and change the value. For example, if we switched to a different power injector vendor, with a different verbiage, instead of changing the power injector values on multiple protocol and scanner pages, we would only have to change the master protocol for power injectors corresponding to the P3T Abdomen entry.”

Using the wiki, the master protocol concept is enabled via transclusion—the displaying of one web page’s content onto another web page. “In this application, it is the displaying of a template page on which multiple different master protocol values are listed onto a single scanner’s protocol page.”

UW-Madison has template pages for the following parts of a CT protocol: indication, oral contrast, prescan instructions, intravenous contrast instructions, field of view, scan description, billing, networking, miscellaneous, reformat instructions, reformat parameters, CT radiographic parameters, bolus tracking parameters, tomographic acquisition parameters (e.g., cine, axial, cardiac, helical scanning modes) and reconstruction parameters. “Different parts have different degrees of redundancy in our protocols across indication, but almost all parts have high levels of redundancy across scanners.”

UW-Madison has successfully replaced its CT protocol documentation with the wiki which is used by technologists for every scan to ensure that the proper reformats, billing, networking and other instructions are being followed.

Setting up the wiki only cost personnel time—about two days of one full-time equivalent (FTE) IT professional’s time; four days of one FTE of the lead CT technologist’s time; seven days of the CT physicist’s time; and two months of two FTE undergraduate time, according to the article. They expect the ongoing effort to maintain protocols to be the largest source of time and money spent to comply with accreditation requirements and maintain an organized and uniform set of protocols whether the system is built in-house or commercially supported.

This wiki-based protocol management system offers several benefits, according to Szczykutowicz et al: 

• The system inherently captures protocol change history and offers discussion pages on which protocol changes can be discussed and documented; 
• It is web-based, allowing easy access to protocol information for centers with affiliate sites spread across large geographical regions; 
• It is well suited to displaying images, tables of technical parameters and textual instructions; 
• The system was built using free software with a robust support base; and 
• It is customizable to fit specific needs, for example, adding additional modalities such as MRI or x-ray fluoroscopic systems.