Process improvements cut fluoro duration and dose

March 4, 2010

Radiation protection and safety measures are crucial to overall patient health, but the implementation of proper processes and protocols can be improved in many healthcare organizations.

Radiation protection and safety measures are crucial to overall patient health, but the implementation of proper processes and protocols can be improved in many healthcare organizations. Inattention to the quality control process may result in missed opportunities for organizational improvement, including the prevention of unnecessary harmful radiation exposure for patients.

According to the National Council for Radiation Protection, (, patients requiring diagnostic radiology procedures have been exposed to more than seven times as much ionizing radiation in recent years as in the early 1980s. Main contributors to this situation could be healthcare economics and defensive medicine, which lead to excessive ordering of imaging procedures. Many organizations are working hard to instill radiation exposure awareness nationally and encourage practitioners to perform necessary diagnostic imaging tests as safely as possible.

This account of Shriners Hospital for Children-Cincinnati's (SHC-C) pursuit and implementation of an effective performance improvement (PI) program may provide guidance for those in other settings who have not yet fully developed protocols and procedures to fit their environment.

SHC-C strives to provide compassionate, quality care for pediatric burn patients. Almost all of our images are obtained at the bedside due to the critical nature of our patients' conditions. Although we recognize that our facility differs from those specializing in other imaging modalities, we highly recommend that all practices using ionizing radiation develop thresholds and procedures for patient safety.


The program provides education for all staff, including management and leadership, supporting the hospital's mission, vision, and strategic plan. Thus employees are empowered to suggest and implement changes for organizational improvement. Managers and staff are held accountable for continuously seeking ways to improve the performance of the organization. Identified performance indicators have been selected and data collection methods and procedures are established. The department leaders are responsible for ensuring that indicator monitoring is a routine activity. This 19-year-long PI process has resulted in a significant reduction of radiation exposure for our pediatric burn patients.

Our determination to improve our safety program began in 1979. SHC-C developed a hospital-wide program to promote integration, collaboration, and communication between all departments, including medical staff and administration.

Between 1980 and 1989, radiation safety indicators were developed in conjunction with competency indicators and monitoring methods. At that time patients received an average of two portable chest x-rays per week, one portable abdominal x-ray per week, and one fluoroscopic procedure per month. Without accurate means of calculating dose, monitoring was based on the number of exposures typical for a critically ill burn patient, and the number of images taken without precautions such as coning or shielding against scatter radiation.

In 1988, with great concern for patient safety, we examined the existing monitors and set a goal to develop a new threshold. We created a maximum midline radiation dose usage ledger that would include the concentrated averages of patient size, body parts most frequently examined, patient clinical condition, and technique variables. After obtaining Institutional Review Board (IRB) approval and in partnership with a radiation physicist, we conducted a study to quantify, using thermoluminescent microchips (TLMs), the amount of radiation received during radiographic exposure in more than 110 procedures (including fluoroscopy). All x-ray procedures included in the study were appropriately ordered by a physician during standard patient care.

TLMs were placed on both the patient and either the x-ray tube or the image intensifier. Data collection consisted of measurements of the distance between the tube and the anterior/posterior surfaces of the anatomical site and the radiographic plate or image intensifier. Additional data included patient age, thickness in centimeters of the body part x-rayed, fluoroscopy or radiographic exposure time, milliamperage (mA) and kilovolts peak (kVp) selected. The physicist measured the entrance, midline, and exit doses and established an acceptable monthly midline radiation dose for SHC-C.

Bedside fluoroscopic procedures were performed using a Picker C-arm at a range of 55 to 70 kVp with an average 5.5 mA, which yielded a patient average entrance dose rate of 450 millirads per minute (range: 300 to 800 mRad/min) and patient average midline dose rate of 100 mRad/min (range: 70 to 170 mRad/min). Bedside radiography was performed using a portable GE AMX-11 mobile unit, which yielded an acceptable midline dose (assuming two chest exposures/week [33 mRad], one abdomen exposure/week [19 mRad], two extremity exposures/month [23 mRad], and one fluoroscopy procedure/month averaging four minutes). This resulted in a dose of 575 mRad/month. A maximum midline dose of 600 mRad/month was set as the threshold until recently, when our function expanded to incorporate new equipment.

The “99 Rule” we introduced in 1991 states, “It does not matter whether the patient is one minute of age or 99 years old; shielding and coning are mandatory!” Radiographers are instructed to apply lead shielding to all patient gonad and thyroid anatomical sites regardless of sex or age. Data analysis indicated that fluoroscopy produced significantly more radiation than the other procedures measured. Policies and clinical protocols for fluoroscopy at SHC-C were revised to include a five-minute fluoroscopy time and a rigorous education process. This education, which includes a written examination, has become mandatory for all staff involved in performing the procedures. Additional items now considered in our performance improvement and quality control programs are listed in the table, above.

Additionally, application of acceptable midline dose, lead apron usage, competency, and film badge use by all staff are monitored.

Many indicators utilized to contribute to a successful analog radiology environment have been eliminated since our recent computed radiography and PACS implementation. Equipment upgrades led to a recalculation of maximum midline dose to 7.5 mGy in 1997 and the addition of equipment-reported ESE (entrance skin exposure) use for C-arm procedures in 2008. Gray (Gy) became our preferred unit of measurement, as most scientific publications had discontinued use of the mRad unit (100 rad = 1 Gy). Future plans include introducing new indicators to monitor the CR exposure index for each image to ensure that staff is selecting appropriate techniques to prevent radiation overexposure. The five-minute fluoroscopy threshold remains a major focus for house officers responsible for performing the procedures. Procedures exceeding five minutes are reported through our PI program, leading to a friendly competition among staff to see who can complete the procedure with the least fluoroscopy time-which, of course, is of great benefit to the patients.

Additionally, we conducted an IRB-approved study to measure the effect of process improvement on bedside fluoroscopy time related to nasoduodenal feeding tube placement in pediatric burn patients.1 Mean radiation exposure was significantly reduced following implementation of standardized policies and development of a clinical protocol for bedside fluoroscopy. Mean fluoroscopy time for nasoduodenal feeding tube placement was reduced from 4.1 minutes to 2.3 minutes. Incidence of exposure times longer than five minutes decreased from 22% to 10%.

In conclusion, with proper processes, radiology procedures can result in minimal radiation exposure for patients and staff.