Knowledge of radiation exposure in common radiological examinations amongst radiology department staff AL Chang, LH Cope, DH Keane, S Wood Presented by Dr AL Chang at Royal College of Radiologists Audit Meeting 18 May 2015

Disclosures Work performed at Radiology department South Tyneside NHS Foundation Trust (STFT) Current workplace – City Hospitals Sunderland NHS Foundation Trust 2

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Background The use of radiological investigations is an accepted part of medical practice justified in terms of clear clinical benefits to the patient, which should far outweigh the small radiation risks. However even small radiation doses are not entirely without risk. A small fraction of the genetic mutations and malignant diseases that occur in the population can be attributed to background radiation 4

The Ionising radiation (Medical Exposure) regulations 2000 and 2006 (IR(ME)R) impose a responsibility on imaging departments to ensure that all exposures to ionising radiation are justified, and that doses are optimized. Organizations and individuals using ionising radiation must comply with these regulations. 5

Background Information available on internet Heightened awareness of radiation exposure iRefer available on intranet Only a third of clinicians receive training in radiation protection and the level of knowledge is low (Soye 2008) On 1 April 2009, the Care Quality Commission (CQC) assumed responsibility from the Healthcare Commission for the inspection and enforcement for incidents in England under Ionising Radiation (Medical Exposure) Regulations

A single view chest x-ray gives an effective dose of 0.015mSv. This amounts to 2.5 days of background radiation 7

THE STANDARD All radiology department staff should have knowledge of the relevant radiation doses for common examinations Target 50% awareness of dose estimation per chest x-ray equivalent 8

Process – Data collection Standard questionnaire (14 questions) To all staff in radiology department Data collected over – First week November 2012 – First week April 2014 Number distributed – 1 st round = 70 ; responders = 54 ( 77%) – 2 nd round = 60 ; responders = 38 ( 63%) 9

Results- responders 10

Introductory question The IR(ME)R) regulations 2000 and 2006 impose a responsibility on imaging departments to ensure that exposures to the following imaging modalities are justified 1.Plain x-rays 2.Ultrasound scans 3.Computed tomography imaging 4.MRI scans 5.Barium contrast studies 6.All of the above 11

Introductory question The IR(ME)R regulations 2000 and 2006 impose a responsibility on imaging departments to ensure that exposures to the following imaging modalities are justified 1.Plain x-rays 2.Ultrasound scans 3.Computed tomography imaging 4.MRI scans 5.Barium contrast studies 6.All of the above 12

Results - data 13

Segment II of questionnaire What is the equivalent dose in ‘chest x-rays’ for the following examinations ? For example The equivalent dose from a single view pelvis x-ray is 20 chest x-rays 14

Answers iRefer – RCR

16 CT HEAD = approximate equivalent of 90 chest x-rays

What is the additional lifetime risk of inducing a fatal malignancy by performing …… 17

Results 18

19 1 st round2 nd round Distribution of number of correct answers

Results 20

Observations – first audit Admin staff and porters are of the opinion that Ultrasound and MRI examination involve radiation exposure 70% (12/17) of administrative staff respond ‘Don’t know’. Radiography Students (4) have performed well – max being 11/13 Highest mark (knowledge) by a radiographer (12/13) 7/13 is average score amongst radiographers - 53% 21

Observations and Actions taken Awareness of radiation exposure in common radiological examinations amongst staff working in radiology department is poor 77% return of forms Radiology nurses have not submitted form Lunch time lectures ( x 4) on procedures undertaken in the department and on IR(ME)R 22

Observations – second round audit Maximum score obtained by 1 consultant radiologist and radiographer Radiology assistants – massive improvement in knowledge – 100% in the IR(ME)R questions and – 67% responders ( cf 17%) achieving > 50% score. – 1 Rad assistant scored 9/13 Admin staff demonstrate some improved knowledge in radiation awareness: – No staff response of ‘Don’t know’. 23

Observations – second round Radiographers – improve on the IR(ME)R question (89% –> 92% correct) – decreased awareness of radiation equivalents (83% -> 53% > 50% marks ) Porters – very low awareness – no improvement. Radiology nurses have not submitted forms 24

Further observations Admin staff indicated that – MRI involved radiation (3) – CT head, CT abdomen involved radiation dose equivalent > 800 CXR (5) Porters continue to believe that – MRI and US involved radiation – Barium swallow study involved no radiation. 25

Further observations Students – indicate CT head and CT chest dose equivalents > 800 CXR – are aware that US & MRI involve NO radiation – are aware that PET-CT involves very large dose > 800 CXR (100%) Overall knowledge of dose equivalent of CT head is poor (30% radiographers, 50% SpR) 26

Limitation Reference - iRefer (2012) for validation of radiation doses and chest x-ray equivalents. However, these doses are relatively higher than STFT radiology in view of iDose in CT and Digital radiography. 27

Staff Responses ‘Thank you for taking the time to inform us’ – Admin staff ‘I now feel better equipped to answer patient questions’ – Radiology Assistant ‘I am able to understand my job better’ – Radiology Assistant 28

Summary Overall there is good interval improvement in awareness of radiation dose equivalents amongst radiology assistants and admin staff. Staff feel valued 29

Recommendations and Action plan Essential attendance at department lecture on procedures undertaken in the department and on radiation protection and Ionising (ME) regulations 2000 and 2006 to all staff Although some staff are not directly involved in radiation exposure, it is essential they are aware of these procedures as they work in a radiation designated area 30

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My thanks to radiography student Sophie for distribution and collection of data sheets in radiology department in second audit cycle. Any questions or suggestions 32

References 1.Soye & Paterson. A survey of awareness of radiation dose among health professionals in Northern Ireland. BJR 2008; 81: The Ionising Radiation (Medical Exposure) Regulations HMSO. 59_en.pdf 3.iRefer. Making the best use of clinical radiology 7th Edition RCR