DR Workflow: Protecting Pediatric Patients

Digital radiography has now largely replaced film across the U.S., making workflows more efficient and offering more sophisticated image processing and storage. Along with these advances, though, comes an adjustment with how radiographers think about radiation exposure. While the switch to digital may be old news, many are still not up to speed on the best practices with regard to limiting radiation exposure, which is especially important in the youngest patients. Fortunately, help is out there.

Before a 2010 conference, the American Society of Radiologic Technologists conducted a survey of technologists to determine what challenges existed in implementing safe practices in digital radiography. It was determined that a concerted educational effort would be required to ensure that x-rays were being conducted with the appropriate exposure, especially for technologists who have been in the field for years and cut their teeth using film-screen radiography.

Among the differences with digital are the indicators for appropriate exposure. Film would instantly show excessive black or white areas indicating over and underexposure, but modern image processing can compensate for this. While this can help in some instances, experts warn of “exposure creep” in which patients are overexposed.

The FDA, in seeking to develop some educational materials, awarded a competitive public contract to the Alliance for Radiation Safety in Pediatric Imaging to develop a safety checklist for technologists performing digital radiography in pediatric patients. This checklist was released last year as part of the Image Gently campaign and published in the Journal of the American College of Radiology (JACR).

Writing in JACR, Susan D. John, MD, chair of the department of diagnostic and interventional imaging at the University of Texas Medical School, Houston, and colleagues noted that a pilot study showed that most technologists who used the checklist found it to be valuable for improving digital radiography in pediatric patients. However, there was a concern that many would not consistently use the list voluntarily.

“Hospital administrators should make radiation safety of pediatric patients a priority by encouraging the use of such educational tools,” wrote John and colleagues. Despite being a common procedure, such direct action will be needed to close the education gap in radiation safety best practices.

“Digital radiographic technology is likely to continue to develop and improve,” they continued. “Education of technologists and radiologists about optimal techniques with existing and changing technology requires broad dissemination of up-to-date information and tools that can be used easily by imaging facilities to ensure best practices.”

Pediatric Digital Radiography Safety Checklist

Prior to Starting the Exam

  • Patient name selected from the worklist.
  • Patient properly identified.
  • Appropriateness of request checked.
  • Explained the exam to the patient or parent.
  • Verified last menstrual period/pregnancy if appropriate.

Image Capture During the Exam

  • Beam > body part > image receptor aligned, source
  • to image-receptor distance checked.
  • Grid only used when thickness greater than 10–12 cm.
  • Patient positioned and body part measured, cassette positioned if applicable.
  • Beam collimated to body part before exposure taken.
  • Technical factors selected based on body
  • part thickness.
  • Shielding and markers placed. Verify correct side
  • of body part.
  • Final adjustment of tube and settings made.
  • Breathing instructions given.
  • Exposure taken.

Image Critique

  • Cassette transported to and processed in reader,
  • if applicable.
  • Images displayed and reviewed, identification confirmed.
  • Image quality reviewed.
  • Exposure indicator/index checked, deviation index compared
  • to target exposure index.
  • Image reprocessed or repeated as necessary.

Following Completion of the Exam

  • Post-processing performed only if necessary.
  • Exam verified and images archived to PACS for reporting.