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TJC Calls for Restraint in Diagnostic Radiation

 |  By cclark@healthleadersmedia.com  
   August 25, 2011

Healthcare organizations must be more judicious in the use of CT imaging and other technologies that use harmful radiation for diagnoses, the Joint Commission said in a sentinel alert Wednesday.

"Diagnostic imaging is a necessary medical tool, but it must be used with great care," Commission president Mark R. Chassin, M.D., said in a statement.

"Although there is still debate about how much is too much radiation, and the timeframe within which radiation can be safely administered, the recommendations in this alert give health care organizations practical strategies to make sure that patients get the right diagnostic imaging tests with the lowest dose of radiation needed to make a diagnosis," Chassin said.


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Instead, the commission suggests that providers consider other diagnostic tests that don't use radiation, such as ultrasound and magnetic resonance imaging.

Hospitals, imaging centers such as mammography screening practices, dental practices and physician offices may all expose patients to layers of radiation, the annual amounts of which have doubled over the last two decades.

But when providers order such tests, they do so usually without asking or being aware of how many other imaging tests involving radiation the patient has recently been exposed to. "Any physician can order radiologic tests at any frequency with no knowledge of when the patient was last irradiated or how much radiation the patient received," the alert said.

"Several recent studies have raised concerns about the risk of cancer from diagnostic imaging, especially in vulnerable populations such as children, young adults and pregnant women," the commission statement said.

Paul Schyve, MD, the commission's Senior Advisor for Healthcare Improvement, said in an interview Wednesday that the issue gained a higher profile because of a number of incidents that came to the Joint Commission's attention, some of which were widely reported by the media and some that were not.

"Over the past year or couple of years, the issue has been that people have started to identify that increasingly people are getting these diagnostic images using radiation, but almost nobody is keeping track of it, and all of a sudden, people are starting to see that this much use has side effects," he said.

"It was like 'To Err Is Human,' the report on medical errors by the Institute of Medicine in 1998. It wasn't that there was suddenly a dramatic increase in errors, but instead it rose to our attention that there's a risk here, a problem here, and we should be addressing this in the interests of patient safety."


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All of a sudden, it seemed, peoples' attention was focused on the issue, "and we at the Joint Commission said, you know, a lot more people are being subject to these risks because we're using these (tests more frequently. We better, all of us, pay attention to this."

Of course, a physician's clinical judgment is important, he emphasized. The radiologist or technician needs to use enough radiation to get an image that is appropriate to read that scan, but not too much, and not so little that the image has to be redone, requiring a second CT and more radiation.

In recent years, several mishaps involving CT imaging, such as one in September, 2009 in which more than 300 patients undergoing CT brain perfusion imaging to rule out stroke at Cedars Sinai Medical Center in Los Angeles, have received doses of radiation eight times what was expected, which caused or carried risks of skin damage, hair loss, cataracts, cancer and other secondary health problems.


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According to a chart from the American College of Radiology and the Radiological Society of North America, diagnostic radiation doses vary significantly, from an intraoral X-ray, which imposes .005 millisievert (mSv), about the amount one would be exposed to from the environment during one day, to a CT of the abdomen and pelvis without, and repeated with contrast material, which imposes 30 mSv, roughly the amount of environmental exposure for 10 years.

The Joint Commission recommends that healthcare settings consider these alternatives:

  • Use of imaging techniques other than CT, such as ultrasound or magnetic resonance imaging (MRI), and collaboration between radiologists and referring physicians about the appropriate use of diagnostic imaging.
  • Adherence to the Nuclear Regulatory Commission's ALARA ("as low as reasonably achievable") guidelines, as well as guidelines from the Society for Pediatric Radiology, American College of Radiology and the Radiological Society of North America for imaging for children and adults, respectively.
  • Assurance by radiologists that the proper dosing protocol is in place for the patient being treated and review of all dosing protocols against the latest evidence either annually or every two years.
  • Expansion of the radiation safety officer's role to explicitly include patient safety as it relates to radiation and dosing, as well as education on proper dosing and equipment usage for all physicians and technologists who prescribe diagnostic radiation or use diagnostic radiation equipment.
  • Implementation of centralized quality and safety performance monitoring of all diagnostic imaging equipment that may emit high amounts of radiation cumulatively.

Schyve said several campaigns are underway to use appropriate doses, such as the "Image Gently" effort to titrate smaller doses for children, and the comparable "Image Wisely" for adults.

He said he expects another Sentinel Alert dealing with overdoses of radiation used in therapeutic healthcare settings.

The Joint Commission's sentinel alert said that it was drawn from its "voluntary reporting system for serious adverse events in health care. The database includes detailed information about both adverse events and their underlying causes."

The Joint Commission is the largest healthcare standards-setting and accrediting organization in the nation.

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