TU-D-201-08: Experience Complying with The Joint Commission Element of Performance On Radiation Dose Index Monitoring

Authors


Abstract

Purpose:

A new Joint Commission element of performance effective July 2015 requires incidents where the radiation dose index exceeds a defined level be reviewed, analyzed and compared to external benchmarks. This work offers a comprehensive review of the CT exams in which the notification level was exceeded and the reason at one academic medical center. This review may help other institutions set reference levels at clinically relevant values.

Methods:

Radiation Dose Structured Reports from each of the 5 diagnostic CT scanners at our institution are automatically sent to our radiation dose index monitoring software platform, Radimetrics from Bayer Healthcare. Global notification levels for CTDIvol and DLP were configured in Radimetrics for head, chest and abdomen studies for 0–2 year old, 2–13 year old and adult age categories. Global CTDIvol notification levels were set lower than the AAPM recommended values. Additional notification levels were configured for specific protocols that do not use AEC or have better or limited image quality requirements. Notifications of exams exceeding the global or protocol specific notification levels were reviewed on an ongoing basis by a Qualified Medical Physicist and the reason(s) for the acquisition or exam exceeding the level recorded.

Results:

Out of 80 notifications for acquisitions or exams exceeding notification levels over an 8 month period, 72 occurred due to large patients or due to implants or external hardware in the scan range. Four instances of the incorrect protocol being selected were recorded and 4 instances of incorrect manual technique application were observed.

Conclusion:

Properly configured notification levels, even below those recommended by AAPM, produce few dose notifications on modern scanners using AEC and/or iterative reconstruction. Using SSDE instead of CTDI for notifications may provide more clinically relevant data on exams well above or below the clinical norm for dose and image quality.

Mark P. Supanich: Global Informatics Advisory Board Member: Bayer HealthCare

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