real world experience: developing dose and protocol...
TRANSCRIPT
![Page 1: Real World Experience: Developing Dose and Protocol ...amos3.aapm.org/abstracts/pdf/127-35538-418554... · CT Protocol Monitoring and Optimization • Joint Commission Standard PC.01.03.01:](https://reader034.vdocuments.us/reader034/viewer/2022042201/5ea176506d010518c3773e0f/html5/thumbnails/1.jpg)
RealWorldExperience:DevelopingDoseandProtocolMonitoring
fromScratch
IngridReiser,PhDDABRDepartmentofRadiologyTheUniversityofChicago
![Page 2: Real World Experience: Developing Dose and Protocol ...amos3.aapm.org/abstracts/pdf/127-35538-418554... · CT Protocol Monitoring and Optimization • Joint Commission Standard PC.01.03.01:](https://reader034.vdocuments.us/reader034/viewer/2022042201/5ea176506d010518c3773e0f/html5/thumbnails/2.jpg)
Outline
• CTprotocolmonitoring– Let’sbuildaprotocolbook!
• CTdosemonitoring
![Page 3: Real World Experience: Developing Dose and Protocol ...amos3.aapm.org/abstracts/pdf/127-35538-418554... · CT Protocol Monitoring and Optimization • Joint Commission Standard PC.01.03.01:](https://reader034.vdocuments.us/reader034/viewer/2022042201/5ea176506d010518c3773e0f/html5/thumbnails/3.jpg)
Fromscratch:statusasof~2015
• Fleetof8-9PhilipsCTscanners,mixofinpatient,outpatient,dedicatedpediatric• Radimetrics installed,about60%ofCTstudiesrecorded
• Events:– Majorsoftwareupgradeonsomescanners(PhilipsiPatient)– 3scannersreplaced,whichaddedGE– Openingofremotefacility
• Personneltransitions(CTmanager)• NodedicatedCTphysicist
![Page 4: Real World Experience: Developing Dose and Protocol ...amos3.aapm.org/abstracts/pdf/127-35538-418554... · CT Protocol Monitoring and Optimization • Joint Commission Standard PC.01.03.01:](https://reader034.vdocuments.us/reader034/viewer/2022042201/5ea176506d010518c3773e0f/html5/thumbnails/4.jpg)
CTProtocolMonitoringandOptimization
• Joint Commission Standard PC.01.03.01: The [critical access] hospital plans the patient’s care. A 25. The [critical access] hospital establishes or adopts diagnostic computed tomography (CT) imaging protocols based on current standards of practice, which address key criteria including clinical indication, contrast administration, age (to indicate whether the patient is pediatric or an adult), patient size and body habitus, and the expected radiation dose index range.A 26. Diagnostic computed tomography (CT) imaging protocols
are reviewed and kept current with input from an interpreting radiologist, medical physicist, and lead imaging technologist to make certain that they adhere to current standards of practice and account for changes in CT imaging equipment. These reviews are conducted at time frames identified by the [critical access] hospital.
![Page 5: Real World Experience: Developing Dose and Protocol ...amos3.aapm.org/abstracts/pdf/127-35538-418554... · CT Protocol Monitoring and Optimization • Joint Commission Standard PC.01.03.01:](https://reader034.vdocuments.us/reader034/viewer/2022042201/5ea176506d010518c3773e0f/html5/thumbnails/5.jpg)
JCrequirements
• CTQualityPolicywasestablished– CTQualityCoreTeamcreated,taskedwithprotocolanddosereview
![Page 6: Real World Experience: Developing Dose and Protocol ...amos3.aapm.org/abstracts/pdf/127-35538-418554... · CT Protocol Monitoring and Optimization • Joint Commission Standard PC.01.03.01:](https://reader034.vdocuments.us/reader034/viewer/2022042201/5ea176506d010518c3773e0f/html5/thumbnails/6.jpg)
![Page 7: Real World Experience: Developing Dose and Protocol ...amos3.aapm.org/abstracts/pdf/127-35538-418554... · CT Protocol Monitoring and Optimization • Joint Commission Standard PC.01.03.01:](https://reader034.vdocuments.us/reader034/viewer/2022042201/5ea176506d010518c3773e0f/html5/thumbnails/7.jpg)
Theprotocols
“Routine critical and systematic review of protocols are necessary not only to ensure that appropriate radiation dose levels are being used but also to verify that other aspects of are
acceptable and consistent with best practice standards.”
Protocolreview:Whatare ourprotocols?
Whataretheparameters?
J Am Coll Radiol 2014;11:267-270.
![Page 8: Real World Experience: Developing Dose and Protocol ...amos3.aapm.org/abstracts/pdf/127-35538-418554... · CT Protocol Monitoring and Optimization • Joint Commission Standard PC.01.03.01:](https://reader034.vdocuments.us/reader034/viewer/2022042201/5ea176506d010518c3773e0f/html5/thumbnails/8.jpg)
Theprotocols
“Routine critical and systematic review of protocols are necessary not only to ensure that appropriate radiation dose levels are being used but also to verify that other aspects of are
acceptable and consistent with best practice standards.”
– Typically>200imagingprotocolsperscanner– NeedtheactualCTprotocols
![Page 9: Real World Experience: Developing Dose and Protocol ...amos3.aapm.org/abstracts/pdf/127-35538-418554... · CT Protocol Monitoring and Optimization • Joint Commission Standard PC.01.03.01:](https://reader034.vdocuments.us/reader034/viewer/2022042201/5ea176506d010518c3773e0f/html5/thumbnails/9.jpg)
![Page 10: Real World Experience: Developing Dose and Protocol ...amos3.aapm.org/abstracts/pdf/127-35538-418554... · CT Protocol Monitoring and Optimization • Joint Commission Standard PC.01.03.01:](https://reader034.vdocuments.us/reader034/viewer/2022042201/5ea176506d010518c3773e0f/html5/thumbnails/10.jpg)
Theprotocols
“Routine critical and systematic review of protocols are necessary not only to ensure that appropriate radiation dose levels are being used but also to verify that other aspects of are
acceptable and consistent with best practice standards.”
– Typically>200protocolsperscanner– NeedtheactualCTprotocols– Notallvendors/modelsproduceaCOMPLETEhumanreadablelistingofprotocolparameters
![Page 11: Real World Experience: Developing Dose and Protocol ...amos3.aapm.org/abstracts/pdf/127-35538-418554... · CT Protocol Monitoring and Optimization • Joint Commission Standard PC.01.03.01:](https://reader034.vdocuments.us/reader034/viewer/2022042201/5ea176506d010518c3773e0f/html5/thumbnails/11.jpg)
Oursolution:gettingscannerprotocols
• Haveserviceengineerretrieveprotocolbackupfiles(Philips)• PhilipsiPatient softwareproducesatext-file(htmlformat)• GERevolutionCTseriesproducecsvfiles– incomplete
• noserieslabels• RevolutionCT:Nopitchfactor,protocolnumberingomitted
![Page 12: Real World Experience: Developing Dose and Protocol ...amos3.aapm.org/abstracts/pdf/127-35538-418554... · CT Protocol Monitoring and Optimization • Joint Commission Standard PC.01.03.01:](https://reader034.vdocuments.us/reader034/viewer/2022042201/5ea176506d010518c3773e0f/html5/thumbnails/12.jpg)
Usingtheprotocols(i.e.,reviewlogistics)
• Textprotocolformattingmaynotbeamenableforreview
• Radimetrics hasaprotocoleditor– Mayormaynotimportyourprotocolparameters
• Oursolution:– Parseprotocolsusingascriptinglanguage(python,matlab,etc)– Generateexcelmasterprotocolforeachscanner
![Page 13: Real World Experience: Developing Dose and Protocol ...amos3.aapm.org/abstracts/pdf/127-35538-418554... · CT Protocol Monitoring and Optimization • Joint Commission Standard PC.01.03.01:](https://reader034.vdocuments.us/reader034/viewer/2022042201/5ea176506d010518c3773e0f/html5/thumbnails/13.jpg)
Acquisitionparameters
![Page 14: Real World Experience: Developing Dose and Protocol ...amos3.aapm.org/abstracts/pdf/127-35538-418554... · CT Protocol Monitoring and Optimization • Joint Commission Standard PC.01.03.01:](https://reader034.vdocuments.us/reader034/viewer/2022042201/5ea176506d010518c3773e0f/html5/thumbnails/14.jpg)
Reconstructionparameters
![Page 15: Real World Experience: Developing Dose and Protocol ...amos3.aapm.org/abstracts/pdf/127-35538-418554... · CT Protocol Monitoring and Optimization • Joint Commission Standard PC.01.03.01:](https://reader034.vdocuments.us/reader034/viewer/2022042201/5ea176506d010518c3773e0f/html5/thumbnails/15.jpg)
Multiplevendors:Consistencyofprotocols
• Perfectparametermatchnotalwayspossible– GE:3.75mmsliceinterval– Philips:4mmsliceinterval
![Page 16: Real World Experience: Developing Dose and Protocol ...amos3.aapm.org/abstracts/pdf/127-35538-418554... · CT Protocol Monitoring and Optimization • Joint Commission Standard PC.01.03.01:](https://reader034.vdocuments.us/reader034/viewer/2022042201/5ea176506d010518c3773e0f/html5/thumbnails/16.jpg)
Currentbestpracticestandards?Acceptable
doselevels?
Radiologistsinindividualsections:
Physicist: Technologist/Radiologist:
protocolsparameters
Scaninstructions Consolidation,
Standardization
Notificationvalues Review:
appropriatedoseandimagequality
Approvalofprotocols
![Page 17: Real World Experience: Developing Dose and Protocol ...amos3.aapm.org/abstracts/pdf/127-35538-418554... · CT Protocol Monitoring and Optimization • Joint Commission Standard PC.01.03.01:](https://reader034.vdocuments.us/reader034/viewer/2022042201/5ea176506d010518c3773e0f/html5/thumbnails/17.jpg)
![Page 18: Real World Experience: Developing Dose and Protocol ...amos3.aapm.org/abstracts/pdf/127-35538-418554... · CT Protocol Monitoring and Optimization • Joint Commission Standard PC.01.03.01:](https://reader034.vdocuments.us/reader034/viewer/2022042201/5ea176506d010518c3773e0f/html5/thumbnails/18.jpg)
Theteam
“Protocol review and improvement efforts should be undertaken by a core team consisting of at least one radiologist, one physicist, and one technologist.”
• Radiologistcanonlyoverseeprotocolsrelevanttotheirsection– GenerallycannotapproveCTprotocolsforadifferentsection(i.e.,thoracicradiologistcannotapproveneuroprotocols)
J Am Coll Radiol 2014;11:267-270.
![Page 19: Real World Experience: Developing Dose and Protocol ...amos3.aapm.org/abstracts/pdf/127-35538-418554... · CT Protocol Monitoring and Optimization • Joint Commission Standard PC.01.03.01:](https://reader034.vdocuments.us/reader034/viewer/2022042201/5ea176506d010518c3773e0f/html5/thumbnails/19.jpg)
Theteam
“Protocol review and improvement efforts should be undertaken by a core team consisting of at least one radiologist, one physicist, and one technologist.”
• CTclinicalmanager(s)overseesCT– IsultimatelyresponsibleforthequalityofCTscansperformedbyhis/hertechnologists
– Has/shouldhaveaninterestinwelldocumented,standardizedCTimagingprotocols
– Supervisesandcommunicateswithalltechnologists• Hasfirepower
![Page 20: Real World Experience: Developing Dose and Protocol ...amos3.aapm.org/abstracts/pdf/127-35538-418554... · CT Protocol Monitoring and Optimization • Joint Commission Standard PC.01.03.01:](https://reader034.vdocuments.us/reader034/viewer/2022042201/5ea176506d010518c3773e0f/html5/thumbnails/20.jpg)
Theteam
“Protocol review and improvement efforts should be undertaken by a core team consisting of at least one radiologist, one physicist, and one technologist.”
• CTclinicalmanager(s)overseesCT– Cangetaccesstoscanners(masteroftheschedule)– Knowstheprotocols– ControlshowCTscannersaresetup(i.e.,passwordprotectionofprotocoleditor)
..DOpasswordprotectyourCTprotocols- allchangesaremadeinthebestintent..
![Page 21: Real World Experience: Developing Dose and Protocol ...amos3.aapm.org/abstracts/pdf/127-35538-418554... · CT Protocol Monitoring and Optimization • Joint Commission Standard PC.01.03.01:](https://reader034.vdocuments.us/reader034/viewer/2022042201/5ea176506d010518c3773e0f/html5/thumbnails/21.jpg)
Must-haves:
• Supportfromtheadministration:– Dedicated,protectedtechnologists’time($$)
• CTmanagersupportcritical– Appointsonededicatedtechnologist(“technicalcoordinator”)– Scheduling:protectedtimeOFFTHEFLOORtohelpwithprotocols
• Difficultiftherearestaffingshortages
– ControlsCTschedule(blockscannertimeforprotocolupdates,notificationsettings)
• Leadtechnologistmaynotbeideal,astheyalreadyhavemanyotherresponsibilities
![Page 22: Real World Experience: Developing Dose and Protocol ...amos3.aapm.org/abstracts/pdf/127-35538-418554... · CT Protocol Monitoring and Optimization • Joint Commission Standard PC.01.03.01:](https://reader034.vdocuments.us/reader034/viewer/2022042201/5ea176506d010518c3773e0f/html5/thumbnails/22.jpg)
![Page 23: Real World Experience: Developing Dose and Protocol ...amos3.aapm.org/abstracts/pdf/127-35538-418554... · CT Protocol Monitoring and Optimization • Joint Commission Standard PC.01.03.01:](https://reader034.vdocuments.us/reader034/viewer/2022042201/5ea176506d010518c3773e0f/html5/thumbnails/23.jpg)
Aprotocolbook
• Protocolbook:– Scaninstructions:Technologist/radiologist– Scanparameters:Physicist
• Protocolbookhelpsestablishstandard– Technologists’willchangescanparametersontheflybecauseA radiologistrequestedscanA tobedoneinacertainway..
![Page 24: Real World Experience: Developing Dose and Protocol ...amos3.aapm.org/abstracts/pdf/127-35538-418554... · CT Protocol Monitoring and Optimization • Joint Commission Standard PC.01.03.01:](https://reader034.vdocuments.us/reader034/viewer/2022042201/5ea176506d010518c3773e0f/html5/thumbnails/24.jpg)
![Page 25: Real World Experience: Developing Dose and Protocol ...amos3.aapm.org/abstracts/pdf/127-35538-418554... · CT Protocol Monitoring and Optimization • Joint Commission Standard PC.01.03.01:](https://reader034.vdocuments.us/reader034/viewer/2022042201/5ea176506d010518c3773e0f/html5/thumbnails/25.jpg)
Ourapproachtobuildingaprotocolbook
• Goal:Buildaprotocolbookthatisflexible,editable,allowingforautomatedupdatingofscanparameters
• Requirements:– Easyexchangewithtechnologists/clinicians(MSoffice)– Automatedscanparameterupdate
• Todisseminate:– UtilizeMSsharepoint
• Use.aspx extensiontodisplayhtml
![Page 26: Real World Experience: Developing Dose and Protocol ...amos3.aapm.org/abstracts/pdf/127-35538-418554... · CT Protocol Monitoring and Optimization • Joint Commission Standard PC.01.03.01:](https://reader034.vdocuments.us/reader034/viewer/2022042201/5ea176506d010518c3773e0f/html5/thumbnails/26.jpg)
Softwaretool
Data entry:clinicalinstructions
Data entry:scanparameters
Data entry:Scanparameterupdate
Clarityoflayout
Access/Publishing
Versioncontrol
MSWord Good Manualorlinkedfields
Manual Userdefined Uploadindividually,openinWord
NeedstobemaintainedbyuserLinked
MSExcel Canbecumbersome(celllayout)
Manualorlinkedcells
Manual Userdefined Uploadindividually,openinExcel
NeedstobemaintainedbyuserLinked
HTML Needspecialeditor,ordirecthtml
Via scripting Via scripting, Userdefined Via scripting,displaysaswebsite(sharepoint)
Needstobemaintainedbyuser
Radimetricsprotocoleditor
Good Automated(depends onCTmanfr)/Manual
Manual Notuseradjustable,poorlayout
Exporttopdfanduploadindividually
Tracksprotocolversion
![Page 27: Real World Experience: Developing Dose and Protocol ...amos3.aapm.org/abstracts/pdf/127-35538-418554... · CT Protocol Monitoring and Optimization • Joint Commission Standard PC.01.03.01:](https://reader034.vdocuments.us/reader034/viewer/2022042201/5ea176506d010518c3773e0f/html5/thumbnails/27.jpg)
CTProtocolMonitoringandOptimization
• Joint Commission Standard PC.01.03.01: The [critical access] hospital plans the patient’s care.
A 26. Diagnostic computed tomography (CT) imaging protocols are reviewed and kept current with input from an interpreting radiologist, medical physicist, and lead imaging technologist to make certain that they adhere to current standards of practice and account for changes in CT imaging equipment. These reviews are conducted at time frames identified by the [critical access] hospital.
A 25. The [critical access] hospital establishes or adopts diagnostic computed tomography (CT) imaging protocols based on current standards of practice, which address key criteria including clinical indication, contrast administration, age (to indicate whether the patient is pediatric or an adult), patient size and body habitus, and the expected radiation dose index range.
![Page 28: Real World Experience: Developing Dose and Protocol ...amos3.aapm.org/abstracts/pdf/127-35538-418554... · CT Protocol Monitoring and Optimization • Joint Commission Standard PC.01.03.01:](https://reader034.vdocuments.us/reader034/viewer/2022042201/5ea176506d010518c3773e0f/html5/thumbnails/28.jpg)
CTdosemonitoring
• Order?Protocol?StudyDescription?Examcard?
• Terminologyisnotdefined.Becarefulwhencommunicating.
![Page 29: Real World Experience: Developing Dose and Protocol ...amos3.aapm.org/abstracts/pdf/127-35538-418554... · CT Protocol Monitoring and Optimization • Joint Commission Standard PC.01.03.01:](https://reader034.vdocuments.us/reader034/viewer/2022042201/5ea176506d010518c3773e0f/html5/thumbnails/29.jpg)
Understandyourworkflow
Referringphysicianordersstudy
CTCHESTW
Radiologyresidentreviewsorderandclinicalhistory,selectsscanprotocol
• Standardcontrast-enhancedchest• Interstitiallungdisease• …
Technologistchoosessize-specificprotocol,ormayadjusttechniqueforpatientsize
• StandardChest• Interstitiallungdisease• …
instructureddosereport“order”,”studydescription”
”protocol”,“examcard”retrievedfromimages
visibleonERMonly“protocolling”
->requiresimagestobesenttomonitoringsoftware
![Page 30: Real World Experience: Developing Dose and Protocol ...amos3.aapm.org/abstracts/pdf/127-35538-418554... · CT Protocol Monitoring and Optimization • Joint Commission Standard PC.01.03.01:](https://reader034.vdocuments.us/reader034/viewer/2022042201/5ea176506d010518c3773e0f/html5/thumbnails/30.jpg)
Dosereporting
• Bystudydescription/order– Imagingprotocolnotknown– Notasusefulforscanparameteroptimization
• Byscanprotocol– Sameimagingprotocolmaybeusedfordifferentorders
• DIR:byorder
![Page 31: Real World Experience: Developing Dose and Protocol ...amos3.aapm.org/abstracts/pdf/127-35538-418554... · CT Protocol Monitoring and Optimization • Joint Commission Standard PC.01.03.01:](https://reader034.vdocuments.us/reader034/viewer/2022042201/5ea176506d010518c3773e0f/html5/thumbnails/31.jpg)
CTdosemonitoring
Wherehaveallthestudiesgone..
![Page 32: Real World Experience: Developing Dose and Protocol ...amos3.aapm.org/abstracts/pdf/127-35538-418554... · CT Protocol Monitoring and Optimization • Joint Commission Standard PC.01.03.01:](https://reader034.vdocuments.us/reader034/viewer/2022042201/5ea176506d010518c3773e0f/html5/thumbnails/32.jpg)
UnderstandyourIT:Whatgetssendwhere?
CTexamiscompletedonscanner
Technologistsendsstudy
DirectlytoPACS
“Smartrouter”
KnowstosendCTstudytoradimetrics
CTexamiscompletedonscanner
Autosend toradimetrics
Initialsetup:
Newsetup:
![Page 33: Real World Experience: Developing Dose and Protocol ...amos3.aapm.org/abstracts/pdf/127-35538-418554... · CT Protocol Monitoring and Optimization • Joint Commission Standard PC.01.03.01:](https://reader034.vdocuments.us/reader034/viewer/2022042201/5ea176506d010518c3773e0f/html5/thumbnails/33.jpg)
ITneedstobepartoftheequation
CTexamiscompletedonscanner
Autosend toradimetrics
Newsetup:
Drawback:Thislinkcanbreakeasily
![Page 34: Real World Experience: Developing Dose and Protocol ...amos3.aapm.org/abstracts/pdf/127-35538-418554... · CT Protocol Monitoring and Optimization • Joint Commission Standard PC.01.03.01:](https://reader034.vdocuments.us/reader034/viewer/2022042201/5ea176506d010518c3773e0f/html5/thumbnails/34.jpg)
Finalwords
• Establishingprotocol/dosemonitoringisnottrivial• Administrationsupport(dedicatedtechnologists’timecosts$$)• Knowyoursystems,yourworkflow
• BuildaDEDICATEDteam– Needtobeonthesamepagewithtechnologists/radiologists– GetsomeonefromITwhoCANHELP
• Knowyourmedicalphysicscolleagues,reachouttosomeonewithsimilarenvironment
Acknowledgements:UChicago CTmanagerandtechnologists,ITgroup,MedicalPhysicsGroup,NickBevins,PhD