Meaningful change: 4 steps to improved CT imaging protocols, fewer dose alerts

Updated Joint Commission requirements have left healthcare providers across the United States working to standardize imaging protocols and analyze why some CT exams exceed predetermined radiation dose thresholds. The authors of a new case study published in the Journal of the American College of Radiology experienced this firsthand, detailing the quality improvement project they helped complete at their own health system.

“Consolidation has resulted in disparate equipment, culture, and needs at various sites,” wrote Matthew E. Zygmont, MD, department of radiology and imaging sciences at Emory University School of Medicine in Atlanta, and colleagues. “Subspecialization in a tertiary care setting also creates the need for an expansive catalog of subspecialty CT protocols. These factors create a complex and at times seemingly untenable system to maintain. Our department invested time and resources to build a repository of master CT protocols to guide consistent care delivery across our health system.”

These are four steps the authors took to meet their goals:

1. Build a master protocol repository

A CT Quality and Safety Committee, which included a CT physicist, CT quality lead technologists and multiple radiologists, was formed. Dose tracking software was then installed in the team’s health system in November 2014.

By May 2015, a repository of master protocols had been completed in the new software and made available to technologists.

“Protocols were initially gathered ‘as they were’ from scanners in the department and were then reviewed by a physicist and subspecialty radiologist,” the authors wrote. “Taking into consideration image quality and dose performance, master protocol parameters were selected from this initial review and further optimized by the CT committee with input from the radiologists and manufacturers’ applications specialists.”

2. Select diagnostic reference levels (DRLs) for each protocol

The team referenced the American College of Radiology (ACR) Dose Index Registry (DIR) to determine DRLs for each CT protocol. The software was designed to “alert” users when examinations had a dose estimate or index above the predetermined DRL. Alerts were sent daily to three individuals: the CT physicists, the lead technologists for that specific equipment and the responsible radiologist. Alerts led to the exam to be reviewed in detail, with the technologists checking if the correct protocol had been used.

3. Conduct a biannual review of dose alerts

A six-month review process began, allowing the team to track its progress over time.

“Review data were shared with the lead technologists at all included sites with recommendations for changes to specific protocols at each site,” the authors wrote. “The standard work practice of performing dose investigations was formalized and taught to all stakeholders.”

4. Implement a “Protocol of the Week”

A “Protocol of the Week” campaign was started to help address a common problem revealed by the biannual reviews— scanner protocol technical parameters not matching master protocols. The Joint Commission specifically calls for “periodic protocol review,” so this campaign also helped the system meet that requirement. When a protocol was changed, the older versions were still saved for future reference. A radiologist and the team’s CT physicist had to review all revisions.

Was it a success?

At first, the authors noted, responses to dose alerts were “less than desired.”

“Staff surveys showed a reluctance to make changes and use new protocols that were available in the online protocol repository,” the authors wrote. “Technologists also often incorrectly attributed alert cause to body habitus or presence of hardware. Technologists acknowledged that older protocols were still in use because ‘I know it works.’”

The CT committee updated its workflow as a response to the results and the feedback. Management became more engaged in the process, and staff members were taught about the importance of the process through a series of lectures.

Over two years, the team reported, the percentage of dose alerts due to protocol errors dropped to 13 percent after being as high as 70 percent. In addition, The overall number of dose alerts dropped 21 percent.

“Now that a majority of protocols have been updated and standardized, we will focus more attention on optimizing radiation dose for protocols with repeated alerts without obvious cause,” Zygmont and colleagues concluded.