1. Jordan Russell, Medical Student, FRCP (C), Brent Burbridge, MD, FRCP (C), Jennifer Tynan, MD

2. Objectives Background Methods Sample Results Discussion Conclusion Future Considerations

3. To promote safe imaging in the NICU. To present our pre-intervention assessment of inappropriately exposed adult fingers on NICU chest radiographs at the Royal University Hospital (RUH) in Saskatoon. To present the incidence of extraneous adult fingers that are cropped out of our images before they are sent to PACS, thus revealing a hidden source of occupational radiation exposure.

4. A 2006 Royal University Hospital publication revealed a disturbingly high incidence of adult fingers on pediatric intensive care unit (PICU) radiographs – an inappropriate occupational exposure to non-diagnostic radiation (Burbridge, 2006). A subsequent study examined the effects of radiation safety seminars on the incidence of adult fingers on PICU chest radiographs, and observed a 66.7% post- intervention reduction (Tynan, et al., 2009).

6. We set out to examine the incidence of adult fingers on NICU chest radiographs at RUH, with a plan to provide educational seminars on occupation exposure to radiation, and analyze any change in incidence post- intervention. Our pre-intervention assessment revealed that the inappropriately exposed digits are sometimes cropped out of the images before they are sent to our picture archiving and communication system (PACS). Prior audits were performed on hard copy images due to recent introduction of PACS at our institution.

7. We set out to unmask this hidden source of occupation exposure to radiation, of which radiologists may be unaware. Image to be added

8. At the x-ray technologist workstation, original NICU radiographs, including the “to-be-cropped before sent to PACS” area were analyzed for adult fingers. Extraneous adult fingers were noted as being either: 1. In the direct beam and seen on PACS, 2. In the direct beam but cropped before being sent to PACS, or 3. In the coned area.

9. NICU chest radiographs present on the RUH X-ray workstation between Dec. 2010 and Mar. 2011, inclusive, were audited. N = 230. Fingers observed were those of RUH Medical Radiation Technologists and NICU staff

12. Incidence: Fingers in direct beam and visible on PACS: 13% (95% CI: 8.7%, 17.4%) Fingers in direct beam, but cropped before being sent to PACS: 10% (95% CI: 6.1%, 13.9%) Fingers in the coned area: 19% (95% CI: 13.9%, 24.1%) Total fingers observed: 42% (95% CI: 35.6%, 48.4%)

13. Possible reasons for this inappropriate occupational exposure to non-diagnostic radiation: Neonatal patients: a challenging population in terms of movement and inability to follow instructions, Time constraints in the NICU, Inadequate understanding surrounding the coned area, An absence of equipment to aid in portable imaging, and The delayed nature of consequences associated with ionizing radiation exposure. (Tynan et al., 2009)

14. Fundamental Principles of Radiation Safety from the International Commission on Radiological Protection (ICRP): Justification of exposure for patients, Optimization of protection for patients and workers, and Dose limitation, where appropriate, for patients and workers. (Wrixon, 2008)

15. Cropping Royal University Hospital NICU radiographs before sending them to PACS for analysis leads to the concealment of an important source of occupation radiation exposure.

16. Radiation safety presentations will now be given to RUH Medical Radiation Technologists, as well as NICU staff. Reminder posters will also be placed in the NICU. Using a pretest-posttest design, our pre-safety intervention sample will be compared to our post-safety intervention sample using a two- sample test for binomial proportions.

17. The incidence of adult fingers seen on NICU chest radiographs at the Royal University Hospital will significantly decline following Medical Radiation Technologist and NICU staff radiation safety education.

18. Burbridge, B. Extraneous Adult Fingers Imaged on Pediatric Chest X- Rays. CARJ 2006,57:269-71. Tynan, J., Duncan, M., and Burbridge, B. Reduction of Adult Fingers Visualized on Pediatric Intensive Care Unit (PICU) Chest X-rays Following Radiation Technologist and PICU Staff Radiation Safety Education. CARJ 2009,60:182-184. Wrixon, A.D. New ICRP Recommendations. Journal of Radiological Protection 2008,28:161-168.