Accelerating Dose Reduction Nationwide

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ascendianBy Neil Singh

January 2013—It’s been six months since the AB510 (SB1237), California’s radiation safety bill, took effect. The Cedars-Sinai incident of 2009, which prompted the California radiation safety mandate AB510, put California’s healthcare imaging practices under the microscope. This incident heightened the public’s awareness of the abuse of radiation in healthcare, and now current legislation and transformation is leading to increased medical imaging patient safety. Today, all 50 states have reached out to the California Department of Public Health-Radiologic Health Branch (CDPH-RHB) for a copy of the radiation safety mandate and have begun drafting similar mandates. So how have California’s healthcare imaging practices changed since the mandate, and what impact did the mandate have on the nation?

The AB510 requires healthcare providers to report any incident to the CDPH-RHB where:

  • A CT exam has been repeated without a physician’s order.
  • Dose values are exceeded when a CT exam was performed that does not include the intended area of the body.
  • CT or therapeutic exposure to a patient that resulted in an anticipated permanent functional damage to an organ or a physiological system, hair loss, or erythema.
  • CT or therapeutic dose to an embryo or fetus that is greater than 50 mSv, that is a result of radiation to a known pregnant individual unless the dose was specifically approved in advance by a qualified physician.
  • Wrong individual or treatment site receives radiation exposure.
  • The total delivered dose varies from the prescribed dose by 20% or more, except in situations where the radiation was for palliative care.

California Today

Healthcare providers have implemented many internal changes in interest of upholding the AB510 requirements. Many institutions were already archiving CT dose screen captures in PACS as DICOM images, and now have made it a requirement to capture all CT dose information in some form (manually or in PACS). Many healthcare providers have updated their workflows to include profiling patient imaging history before scanning, and radiologists are dictating CTDi and DLP values in every CT report. Dose reduction software has been installed to reduce total CT dose delivered.  CT volumes have declined for many; however, there are multiple external factors contributing to the decline (ie, the economy). Managers are recognizing increased communication between ordering physicians and the radiologist on best patient imaging practices. Some providers have also admitted reporting incidents to the CDPH-RHB for exposure to wrong body part and reimaging without physician request.

The Nation

This year, I was involved with deploying a number of enterprise wide radiation safety transformations in states including New York, Florida, and Tennessee. These large Integrated Delivery Networks (IDNs) implemented an enterprise level radiation safety program. Many organizations also implemented radiation dose repository software, capable of tracking and displaying aggregate/accumulative dose values. Some institutions included other modalities like angiography/special procedures and digital mammography as part of the patient’s accumulated dose history. Internal radiation safety teams were constructed to regulate dose threshold breaches and manage mitigations related to radiation dose incidents.

The word is out, and healthcare providers are energized about driving radiation safety transformations nationally. Those organizations that progressively improve their dose reduction programs will benefit from efficiencies across people, processes, organizational and technology components, and ultimately the level of patient care they provide.

Building a Good Program

The path to leading any new transformation is knowing where to begin; and are two incredible resources that can help a transformations leader understand the radiation safety initiative, as well as provide a guideline for CTDi and DLP dose thresholds. It is imperative that transformation leaders build strong teams with the right people to keep the teams energized and focused.  A good program includes an analysis of the existing imaging workflow, prevailing technology, and a comprehensive enterprise strategy that incorporates the changes from the upcoming program. Risk management, quality controls, patient education, and policies and procedures should be reassessed, updated, and distributed.

The radiation safety initiative will only gain momentum.  The imaging landscape will be different on the mandate’s year anniversary, and more states will begin leading their radiation safety transformations. The early adopters will be perceived as leaders and set a new standard in imaging practices. The initiative will only gain more attention, and we can expect a federal mandate sooner than later.

Neil Singh is a consultant at Ascendian Healthcare Consulting. If you have questions you can contact Neil via email

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