A qualitative evaluation of direct radiography in pediatric clinics

OzetAmac: Gunumuzde radyasyona maruziyetle olusabilecek riskleri geri dondurebilecek bir yontem henuz yoktur. Bu nedenle tani ve tedavi icin x isinlari kullanirken “A(s) L(ow) A(s) R(easonably) A(chievable)”, yani “mumkun olan en az dozla bu isi basarmak” prensibini kullanmak onemlidir. Cocuk klinigimizde tanisal amacli cekilen direk radyografileri bu amacla kantitatif olarak degerlendirdik. Materyal ve Metod: Universite hastanemiz cocuk kliniklerinde (poliklinik-servis-yogun bakim) ocak 2015 basindan mart 2015 sonuna kadar muayene edilip tanisal amacli direk radyografi cekilen hastalar retrospektif olarak calismaya alindi. Hasta listesi otomasyon uzerinden elde edildi. Onuc farkli hekime ait cekim istekleri vardi. Hasta listesine uyan radyoloji goruntuleri PACS (Picture Archiving and Communication System) sistemi uzerinden DICOM formatinda klasore yedeklendi. Elde edilen goruntuler OsiriX adli acik kaynak yazilim ile islenerek siniflandirildi. Veritabani siralandi. Bu veritabani ikiye ayrilarak iki ayri radyoloji uzmaninca BASICS (Beam-Dozlama, Artefact-Artefakt, Shielding-Koruma, Immobilization-Sabitleme, Collimation-Kolimasyon, Structures-Yapilarin uygunlugu) prensiplerine gore degerlendirildi. Sonuclar bilgisayar ortaminda istatistiksel olarak yorumlandi. Bulgular: Calismaya toplam 552 hastadan elde edilen 711direk radyografi alindi. Hastalarin yas araliklari bir gun ila 18 yil araliginda idi. 158 hastaya birden fazla film cekilmisti. Cekilen grafiler agirlikli olarak Akcigeri goruntuleme amacliydi. Bunun yaninda ayakta direk batin, Water’s, el bilek grafisi gibi muhtelif grafiler vardi. 711 cekimin %74 (n=528)’inde KVP degeri vardi. Beam (Dozlama)’in diger bilesenleri olan Part Thickness(cm),mA, Time,mAs, SID, IR size, Exposure Indicator (EI) verileri grafilerin hicbirinin metadatasinda yoktu. Yuzde bes (n=36) vakada artefact (artefakt) gozlendi. Sadece 4 vakada (<%1) shielding (koruma) yapilmisti. Immobilisation (sabitleme) orani %98 (n=698) oraninda uygundu. %48(n=342) vakada uygun collimation (kolimasyon) vardi. Digerleri yetersiz idi. Dijital cropping (kesme) sadece 32 cekimde uygulanmisti (%4.5). Vakalarin %90’inda (n=639) grafide olasi gereken structures tamdi, yani grafide gorulmesi istenen organlar cekim alaninda gorunuyordu. Sonuclar: Beam (dozlama)ya ait metadatanin olmadigini gorunce cekim senaryolarini izledik. Tum cekimler oncesi bu degerler giriliyordu. Ancak konunun onemi uretici firmalarca bilinmediginden veri tabanina kaydedilmedigi belirlendi. Bulgularda da goruldugu gibi BASICS prensiplerinin immobilizasyon disindaki tum bilesenleri iyilestirmeye aciktir. Farkindalik olusmasi gerekenler cocuk hekimleri basta olmak uzere radyoloji teknisyenleri, radyoloji doktorlari ve yoneticilerdir. Konunun cozumu olcme, degerlendirme, planlama ve uygulamayla olacaktir. Calismamizin sonunda, kurumumuzda BASICS egitim calismalarina baslanmistir.


INTRODUCTION
X-rays have been used in the diagnosis and treatment of diseases ever since their discovery by Wilhelm Conrad Rontgen (1). In the beginning, only direct radiographs were taken. Today, Computed Tomography, angiography and forms of scopy are widely used for diagnostic purposes. Direct radiography is the main X-ray method that is used for diagnosis (2).
The detrimental effects of X-rays have been known from the beginning of their use in diagnosis and treatment. These adverse effects are defined as "deterministic" in the acute stage and "stochastic" in the long term (3). Especially since life expectancy is longer in children, the probability of "stochastic" effects emerging is higher.
No method exists even today that reverses the risks of exposure to radiation (4). The best way of protecting against harmful effects is to determine the right indication. This however is best attained through a program of additional medical training and postgraduate remedial training and through the introduction of clinical guidelines. In setting forth indications, the recommendation is to abide by the principle of A(s) L(ow) A(s) R(easonably) A(chievable) when dealing with X-rays in diagnosis and treatment (5), (6) .
Various initiatives have been developed to achieve ALARA. One of these is the "Image Gently" group that is an alliance to achieve ALARA in the pediatric group of patients (7), (6). The "Image Gently" group has set forth the standards of BASICS to determine common definitions and measurements.
At our pediatric clinic, we tried to evaluate the direct radiographs taken for diagnostic purposes according to the BASICS principles, working with the goal of identifying areas for improvement.

MATERIALS AND METHOD
Firstly, the approval of our University's ethics committee was obtained. The direct radiographs taken for diagnostic purposes from patients (7452 patients, 15,710 examinations) presenting at our university hospital's pediatrics clinics (polyclinic-service floor-intensive care) over the period from the beginning of January 2015 to the end of March 2015 were retrospectively assessed in the study.
A patient list was obtained from the computer records. Thirteen different physicians had submitted radiography orders. The radiological images matching the patient list were filed via PACS (Picture Archiving and Communication System) in the DICOM (Digital Imaging and Communication in Medicine) format. The images obtained were processed and classified with the open-source software OsiriX (8). The database was formatted. Dividing the database into two sections, two separate radiology specialists evaluated it in terms of the optimization of the BASICS (Beam-Artifact-Shielding-Immobilization, Collimation, Structures) principles.
The Beam (dosing) metadata of the radiographs were reviewed in terms of kVp, Part Thickness (cm), mA, Time mAs, SID, IR size, and Exposure Indicator (EI) data.
Artifacts were defined as unwanted images appearing in the patient's radiograph.
Shielding was defined as the protection from radiation of the patient's more sensitive organs, such as the thyroid gland, breasts, gonads and eyes that are in close proximity to the target field, using lead material during the imaging procedure.
Immobilization was defined as fixing the patient's position during the imaging procedure to prevent image distortion resulting from the patient's movement.
Collimation was defined as using a special setup to prevent X-rays from beaming outside of the target area during the imaging.
The procedure whereby the resulting image is digitally cut to display collimation was defined as Cropping.
The term Structures referred to the optimal imaging of the entirety of the target tissues or organs in the radiograph.
The results were statistically analyzed on the computer with Microsoft Excel.

RESULTS
A total of 7,452 pediatric patients were examined 15,710 times over the course of the study.
The study made use of 711 direct radiographs obtained from a total of 552 patients. The patients' ages ranged from 1 day to 18 years. More than one imaging had been made for 158 of the patients.
The rate of patient imaging was 7.45%.
Most of the radiographs were taken to provide imaging of the thoracic region (Lung X-ray, Telecardiogram, Chest X-ray). In addition to these, the radiography also included among others, standing direct abdominal radiographs, Waters views, and wrist radiographs (Table 1). BASICS findings are summarized in Table 2.  (Figure 1).
The minimum kVp value entered for the 298 Chest-PA radiographs was 52, maximum was 78, the mean was 63.19. In the telecardiograms, the minimum value for 64 cases was 63, maximum value was 120, the mean was 75.93. The kVp value in the telecardiograms, which was 120, appeared in the pediatric cases of ages 14 months-14 years and all were taken on the same device. Artifacts were observed in five percent (n=36) of the cases (Figure 3). The number of artifacts was greatest in the Chest-PA radiographs (n=25, 69%); they were also seen in the pelvis radiographs (n=4, 11%), standing direct abdominal radiographs (n=4, 11%), knee radiographs (n=2, 0.6%) and ankle radiographs (n=1, 0.3%). The age of the youngest child whose film revealed artifacts was 2 months, the oldest was 17 years old, and the mean was 3.9 years. Age distribution for the artifacts has been shown in a graph ( Figure 2). The objects that generally constituted artifacts were pants buttons, zippers, bodysuit snaps and necklaces.
The goal of shielding was to protect the gonads, breast tissue, the thyroid and eyes. Shielding had been performed in only 4 (<1%) of the cases (Figure 4).
The immobilization rate, at 98% (n=698), was optimal. It was observed that in infants, parents helped in the immobilization and that supporting immobilizing devices were not used ( Figure 5). The 3 cases that were unsuccessful were adolescents; all of the others were of the ages 4-35 months. Lung PA and chest films were the most unsuccessful (n=9, 69%). These were followed by Waters views (n=2, 15%), wrist X-rays (n=1) and standing direct abdominal radiographs.
In 90% (n=639) of the cases, the structures were optimal, that is, the desired organs were within the imaging field. Almost all of the deficient films were Chest-PA radiographs (n=27, 93%). Other deficiencies were seen in standing direct abdominal radiographs (n=1) and ankle (n=1) radiographs.

DISCUSSION
Patient safety involves preventing and protecting the patient from the detrimental effects of any health service that a patient may undergo. Radiation safety is one of the important components of patient safety.
Pediatric Patient safety is even more important. This is because pediatric patients do not have decision-making competence and it is generally their parents who are involved in the process of diagnosis and treatment.
Children have a higher risk of exposure to the adverse effects of radiation (6). Calling attention to safety issues with regard to pediatric patients, determining the problems and finding/implementing solutions for these issues are among the basic duties of the physician. This is why it is important to be familiar with the science of patient safety, to learn about the culture of safety, and to determine appropriate strategies.
Pediatricians, radiologists, radiology technicians and administrators need to work together to prevent possible harmful effects associated with radiation (6). This study was initiated as a result of our awareness of our responsibility in this respect.
The principle in general quality culture that "you can't know if you can't measure it, and if you don't know, you can't manage it" is pertinent here. In our study, therefore, we set out to investigate to see the areas associated with radiation that are open to measurement and improvement. Besides the direct x-ray laboratory, our hospital also houses computed tomography, mammography, scopy and angiography units. We chose to work with direct radiography since evaluation of criteria is simpler and learning the technology is easier, and also because x-rays are the most frequently ordered type of radiography (2).
Most of the radiographs (n=438, 61.6%) were taken of the chest region. This is consistent with the findings of Dorfman et al. (2) Beam evaluations were technically the most challenging for us. The hospital had 2 different brands of digital x-ray devices, 2 different brands of computed radiography (CR) machines. The metadata of these devices used different nomenclature for the data fields. Among the metadata that we were searching for here, only kVp values were available in all the devices. The rate of recorded kVp values was 74%.
Jurado-Román et al. developed simple protocols to reduce doses by 57% in fluoroscopic laboratories without compromising quality (9).
As an indirect indicator of imaging signals-noise rates and digital imaging quality, the Exposure Indicator is a detector that provides feedback on predictable exposure (7). It is important in achieving ALARA that each hospital determine EI values in their own devices for all imaging fields (10).
With a rate of 1%, shielding was the area in which we were the most unsuccessful. It was observed that  although all the technicians knew how to protect the gonads, this was not done, and further, there was a general lack of knowledge about protecting the eyes, breast and thyroid.
Immobilization, at a rate of 98%, was among the successful areas. Adolescents and children were largely directed through the microphone system in the preliminaries and procedures to follow. The immobilization of infants is achieved with the help of one of the parents or a member of the family. This means that those assisting in the process run the risk of direct or indirect exposure. It was learned that assistive immobilization devices were not being used in the clinics.
Collimation, with an implementation rate of 48%, was observed to be one of the areas open for improvement. Digital cropping was observed in 32 cases. As opposed to its many advantages, digital cropping is a disadvantage of digital imaging since it is regarded as a means of concealing the failure to perform collimation for the sake of convenience and is thus a matter that must be given attention.
It was seen that a 90% rate of success was achieved in terms of structures. Almost all of the deficient films were Chest-PA radiographs (n=27, 93%).
Technicians working in radiology clinics, especially those serving pediatric patients, must have remedial training in this area (11). We observed that implementing the Image Gently (http://ww.imagegently.org) BASICS principles is an advisable methodology for use in qualitative evaluation and improvement.