The Golden State Goes Live with CT Dose Reporting
Under ordinary circumstances, the media spotlight is business as usual in Tinseltown. But in October 2009, it wasn't Hollywood hijinks that occupied the limelight. Instead, it was the overradiation of 206 patients during CT exams at Cedars-Sinai Medical Center in Los Angeles.  

Several lawsuits and investigations later, the state stepped in. California Gov. Arnold Schwarzenegger inked SB 1237—the California Dose Reporting Law—in September 2010. Designed as a quality control initiative for CT scans, the bill plunges imaging stakeholders and hospitals into uncharted waters.

Roadmap for success

The 368-bed Sharp Memorial Hospital in San Diego may provide a model for SB 1237 compliance. The hospital's strategies center on a common denominator—teamwork.

When California enacted SB 1237, Sharp's hospital leadership team set two goals: comply with the law and acquire clinically useful diagnostic images with as little radiation exposure as possible.  

The primary challenges with the law are accreditation, electronic collection and reporting of CT dose data, says Michael L. Puckett, MD, chief medical officer of San Diego Imaging Medical Group. Accreditation for scanners and annual verification of radiation doses by a medical physicist present significant challenges. Accreditation, which can be costly and time-consuming, requires facilities to bring in a qualified medical physicist to perform beam assessment, says Bette W. Blankenship, MS, DABR, medical physicist. This could be extremely difficult for smaller facilities that may not have a medical physicist on staff, she adds.

The law also requires each facility to transmit CT dose reporting pages through the RIS and PACS. The dose page is sent to the PACS and dose-specific imaging variables—CT dose index (CTDIvol) and dose-length product (DLP)—are recorded in the RIS. The bill also requires facilities to record the CT dose in each patient's record. Blankenship notes that it is tricky to pull data from the imaging device or search those data from each dose page and send them to the RIS.

There is, however, a hefty plus to the passage of SB 1237. "The bill will help physicians to look for trends and cut down on our imaging exams," Puckett says.

The law has reminded Sharp's staff to pause and ask: "Are we imaging efficiently? Are we all imaging the same way? Are protocols static throughout the entire organization?"

The first step is to reassess protocols, says Blankenship. In fact, Sharp staff worked vigorously to re-examine, reset and overhaul hundreds of pre-set protocols on its four CT scanners.

"Our CT protocols were not very well-monitored as far as radiation dose," says Jonathan M. Gurney, MD, medical director of radiology for Sharp. Although the hospital's protocols did not exceed dose thresholds and were far from overradiating patients, many pre-set protocols were based on physician preference, rather than standardized protocols.

"If you have not been keeping track of your protocols in a systematic manner, it is likely that you have five to six different protocols per body part," says Gurney. He advises facilities to start by filtering exam protocols that are used less often and find the ones that make the most sense from an imaging standpoint.

Sharp wiped out unused or unsanctioned protocols and replaced them with facility-wide, approved protocols, which has helped standardize emitted dose. Re-examining these protocols has helped cut down on radiation dose in multiple exams. Dose for sinus CT studies has been reduced nearly 70 percent, without any loss of diagnostic accuracy. Now, the revised CTDIvol for a sinus series is 9 mGy, compared with the American College of Radiology's reference level of 75 mGy.

But challenges still lurk. A major one has staff performing an archaic task—sifting through some dose reports by hand. Two scanners have the capability to electronically capture CTDI and DLP data, but the PET/CT system and one CT scanner do not.

Because each CT scanner has 50 to 100 scan types, some with multiple series of scans for one protocol, the manual review is quite time-consuming. A potential fix may be in the works. The hospital is considering investing in an IT software patch that could update the two scanners and push these data to electronic storage.

No I in team

Teamwork helps mitigate the challenges of complying with SB 1237, according to Blankenship. One of the starring players is the medical physicist, who typically handles protocol analysis.

Along with Blankenship, the medical director of radiology, radiation safety officer and CT lead technologists sit on Sharp's radiation safety committee. Other representatives include cath lab and radiation oncology staff.

During monthly meetings, the group collaborates to design protocols and procedures that may help lower dose. Additionally, best practices are shared.

After reviewing protocols, the group discusses ideas on how to further decrease dose. The group also weighs other factors including beam energy, beam quality and image noise index. "Comparing dose [and discussing preferences and successful strategies] gives us the opportunity to glean ideas, bring them back to our scanners and further reduce dose to assure excellent diagnostic images," says Blankenship.

"We now ask ourselves: how can I be more dose efficient?" she adds.

Blankenship and colleagues have begun rigorously training staff to understand appropriate doses. Questions answered during training cover process to protocols: How will we best refer patients? How will we deliver dose? What is the proper terminology to use?

"The big changes are cultural, not mechanical or logistical," says Puckett. Motivating various stakeholders to prioritize radiation exposure is key to success.  

SB 1237 remains a bit of work in progress as there are still some kinks in its language, says Blankenship. For example, the bill asks for the radiology report of a CT study to be included; however, it is unclear whether this means the radiologist's report or the radiation dose report. An assembly amendment is in the works to clarify these requirements.

Meanwhile, providers in California and elsewhere are keeping an eye on how the law affects hospitals, radiology departments and, importantly, patient care.