A novel quality assurance method in a university teaching paediatric radiology department

Quality assurance of paediatric lateral chest radiographs

INTRODUCTION

Lateral chest radiographs aid in paediatric clinical practice in countries where the diagnosis of primary pulmonary tuberculosis (PTB) still relies heavily on the chest radiograph. This study aimed to create a validated quality assurance (QA) tool investigating the diagnostic performance of this projection by applying this to a database of lateral chest radiographs in children with suspected PTB.

METHOD

The QA tool was built to include a compilation of criteria from the different sources, accompanied by graphic representations and objective measurements where appropriate. Each defined criterion (radiographic error) was evaluated by implementing the QA tool on 300 radiographs, scored by three readers. The sample was subjected to two separate sets of data analysis, based on averages, and on majority decision methodology.

RESULTS

The QA tool was based on existing published criteria, as well as under-collimation and under-inspiration, two de novo criteria. For the total 900 reads, errors were categorized as patient-related in 681 (75.7%) and radiographer-related in 421 (46.8%) and 122 (13.6%) had no errors. The average number of errors per radiograph ranged from 0.9 to 4.7 errors out of the 11 quality factors reviewed. When considering the majority decision, the median errors per radiograph was 1 (IQR 1-2) (range 0-5). Inter-rater agreement varied for different criteria.

CONCLUSION

A novel QA tool for evaluating lateral chest radiographs was developed which requires further efforts of refinement regarding criteria such as exposure, field of view: under-collimation, and motion artifact, which remain subjective. The designed QA tool will allow comparison of radiograph quality before and after interventions. Furthermore, the tool can be used in tackling childhood PTB in low- and middle-income countries (LMICs) since the hallmark of the disease is lymphadenopathy, which is often depicted best on lateral chest radiographs.

Short-term impact of pictorial posters and a crash course on radiographic errors for improving the quality of paediatric chest radiographs in an unsupervised unit - a pilot study for quality-assurance outreach

BACKGROUND

Chest radiography is the most commonly performed diagnostic X-ray examination. The radiation dose to the patient for this examination is relatively low but because of its frequent use, the contribution to the collective dose is considerable. Optimized image quality not only allows for more accurate diagnosis but also supports radiation protection, which is particularly important in children.

OBJECTIVE

To determine whether the introduction of a poster of technical errors in paediatric radiography accompanied by a short lecture (crash course) for radiographers on common errors can sustainably decrease the number and rate of these errors in an unsupervised radiology department (without a paediatric-trained radiologist or paediatric-trained radiography personnel).

MATERIALS AND METHODS

We conducted a pilot study for quality-assurance outreach, with retrospective and prospective components, in the paediatric radiology department of a teaching hospital. The technical errors in frontal chest radiographs performed in the unit were assessed by quality-assurance analysis using a customized tick-sheet. The review was performed before and after an intervention that involved a half-hour crash course and poster displays in the department. We compared the rate of technical errors made before and after the intervention.

RESULTS

There was statistically significant improvement in quality of radiographs (P < 0.0083) performed immediately after the intervention. There was a statistically significant decline in the quality of radiographs performed >2 months after the intervention.

CONCLUSION

A simple intervention of a crash course and poster placement resulted in improved quality of paediatric chest radiographs. A decline in quality after 2 months suggests the need to repeat this or another type of intervention regularly.

A comparative study of collimation in bedside chest radiography for preterm infants in two teaching hospitals

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Potential factors influencing non-optimal image collimation in the setting of bedside chest X-ray in preterm infants were investigated.

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A comparable rate of optimal images was observed in two hospitals.

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Size, weight or disease severity had no influence on collimation quality.

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Unrelated to the years of experience a large variation of the technician in correct collimation was noted (18–86%).

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Individualized quality control and education is necessary.

Objective

Unnecessary exposure of the abdomen, arms or head may lead to a substantial increase of the radiation dose in portable chest X-rays on the neonatal intensive care unit. The objective was to identify potential factors influencing inappropriate exposure of non-thoracic structures in two teaching hospitals.

Methods

The study analysed 200 consecutive digital chest radiographs in 20 preterm neonates (mean gestation 25 ± 1 weeks). Demographical data, tube settings and exposure parameters were recorded. To grade the collimation, we used a scoring system with a maximum of 12 exposed non-thoracic structures. Length of gestation, age, the radiographer, years of experience in performing X-rays and the number of in situ catheters or lines, were correlated with collimation quality.

Results

There was no significant difference between the rates of optimal images obtained in the two hospitals (0.32 vs 0.39, n.s.). Scores showed that most suboptimal images had only mildly reduced image quality (1.40 ± 1.38 vs 1.20 ± 1.43, n.s.). Length of gestation or presence of surgical drains, catheters and tubes had no obvious effects on the exposure of non-thoracic structures. Large intra-individual variation in optimal collimation (14–86%) was noted for the radiographers in both hospitals; this was unrelated to their respective years of experience.

Conclusion

In our study, the only identifiable factor influencing the collimation of portable chest radiographs in preterm infants was the radiographer’s dedication and awareness. There were no apparent differences between the hospitals investigated. Exposure of non-thoracic structures was relatively frequent and mainly involved the proximal humeri.

Quality assessment of X-rays interpreted via teleradiology for Médecins Sans Frontières

Summary

Médecins Sans Frontières (MSF) is a humanitarian organisation which provides emergency medical aid in challenging settings; field staff often diagnose and treat patients using limited resources and without the expertise of specialists. Teleradiology is available for MSF sites which use digital computed radiography (CR) imaging or conventional film and chemistry. We conducted a retrospective study of the quality of X-rays utilised by MSF for teleradiology diagnosis over a one-year period. All plain X-ray examinations referred for interpretation using two MSF teleradiology platforms in 2012 were assessed against 15 image criteria and further evaluated as being either diagnostic or non-diagnostic. The sites studied sent an average of 115 images (range 10-452). Images were a mixture of chest, skeletal and abdominal radiographs. The majority of the images were CR (n = 597, 74%). Three sites were MSF/Epicentre installed and operated (Epicentre is a research facility affiliated with MSF); five sites were operated by the ministry of health, imaging patients referred by MSF. The sites performing poorest for quality were all facilities which used film and chemistry (53% non-diagnostic images). The sites performing better for quality were facilities which used CR digital imaging (12% non-diagnostic images), two of which had also undergone radiographer training. Our study suggests that transitioning to CR digital imaging has the potential to improve image quality compared to film and chemistry. Radiography training should be made a priority for all sites with X-ray services. The continued utilisation of X-ray services by MSF where images have proven to be consistently poor should be re-considered.

Effective radiology teams

Teams can be very helpful in quality improvement, the service recovery process, and reengineering. Teams can increase organizational communication, quality, productivity, and morale. However, not all teams work well, and some can waste time, cause resentment, and be a net negative for an organization. This article summarizes some of the steps in getting a team to a good start, keeping it running well, having effective meetings, and correcting some common problems.

Paediatric personnel extremity dose study

Concern has been expressed in paediatric radiology regarding the magnitude of the extremity dose received by attending personnel during routine fluoroscopic procedures and CT. Common procedures that may be of short duration in adults can be quite the opposite in paediatric patients. The extremities of attending personnel are more likely to be exposed to the primary beam and for a longer period of time owing to a variety of reasons such as assisting in the procedure or physically restraining the patient during the examination. During the period mid 1998 to mid 2000, two paediatric radiologists, four senior radiographers and two paediatric nurses were monitored using ring thermoluminescent dosemeters (TLDs). Each participant wore the ring TLD on either the left or right ring finger, depending on which hand the individual favoured. Left/right asymmetrical studies were not conducted, nor were records kept of whether an examination used a grid or gridless technique. Initial apprehension about higher paediatric fluoroscopic and CT extremity doses was dispelled as a result of this quantitative dosimetric study.