Making radiology safer

A balanced strategy recognising the pros and cons is the need of the hour

The medical use of ionising radiation is expanding worldwide. A rise in advanced technology has opened new horizons to diagnostics and interventional radiology, nuclear medicine and radiotherapy, improving the patient care but this comes with an extra responsibility of implementing and handling the safety aspects associated with this field. Radiation safety is important in all aspects of radiology, not only because of regulatory requirements but also because of personnel and patient considerations. While, majority of healthcare organisations implement it rigorously, some still need more standardisation of guidelines and other aspects given by authorities like Atomic Energy Regulatory Board (AERB).

Explaining about the rigorous licensing process by the Atomic Energy Regulatory Board, Dr Mohnish P, Consultant-Interventional Radiologist, Gleneagles Global Health City, Chennai said, “Hospitals and clinics go through a rigorous licensing process by the Atomic Energy Regulatory Board to procure and commissioning these equipments. In all these places, Radiation Safety Officers (RSO) or Radiologists (Doctors) are licensed to procure and install the machines. They operate these equipments with the help of technicians (Radiographers), who guide the patients, position the patients, do the investigation and get the imaging for interpretation. Every RSO, radiologist and radiographer has to make sure about radiation safety to the patient and for themselves.”

Talking about modern day radiology, Dr Bhaskar M V, Lead of Radiology Department and Interventional Radiologist, SPARSH Hospital highlights,Most of the modern day radiology tools such as CT scans, X-rays, mammography, interventional treatments using fluoroscopy, PET CTs, radiotherapy units all of these use ionising radiations. In modern medicine, the usage of these diagnostic tests has significantly increased because all treatments that are evidence-based need diagnosis and specific treatment. While there has been an increase in the usage of ionising radiation, we should also be cognisant of some of the effects that these invisible harmful X-rays can cause on cellular tissues.”

Radiation protection: The challenges and long-term goals

The global radiation detection, monitoring, and safety market is expected to grow at a CAGR of 6.9 per cent to reach USD 3.1 billion by 2026 from an estimated USD 2.2 billion in 2021. The key factors propelling the growth of this market are growing security threats, the growing prevalence of cancer worldwide, increasing radiation safety awareness, growth in the number of PET/CT scans, and the increasing usage of nuclear medicine and radiation therapy for diagnosis and treatment.

Dr Bhasker while stressing on the principles of radiation protection added, “The main principle of radiation protection include Justification of practice and optimisation of radiation usage. It’s very important to really understand the appropriateness and need for a scan involving radiation. For example, when a CT scan is recommended, it’s important to evaluate if the scan is really necessary or not, or if other possible alternatives of non-radiation scan like ultrasound or MRI can be used. The appropriateness of the radiation test should be evaluated in each and every case, especially for children and for women in the reproductive age group.”

Explaining about the ways to minimise the risk of radiation, Dinesh K Baghel, Sr Medical Physicist cum Radiation Safety officer, Department of Radiation Oncology, Asian Institute of Medical Sciences says, “The most powerful tool for minimising the risk is appropriate performance of the test and optimisation of radiological protection of the patient. These are the responsibility of the Radiation Safety Officer (RSO) or Medical Physicist. The basic principle of patients’ protection in radiological X-ray investigations is that necessary diagnostic information of clinically satisfactory quality should be obtained at the expense of a dose as low as reasonably achievable (ALARA), taking into account social and financial factors. It should be emphasised, that radiological interventional procedures lead to higher doses to patients than normal diagnostic investigations. However, indications for such procedures in most cases result from a high risk from conventional surgery. Appropriate modern equipment and training of personnel allow the patients’ exposure to be limited to an acceptable level, securing a very high benefit/risk ratio.”

Talking about the challenges, Dr Vijay Jayakrishnan; Senior Consultant, Neuroradiology & Interventional Radiology, Lead Consultant, Clinical Imaging and Interventional Radiology Aster Medical Imaging said, “One of the foremost challenges to ensure ongoing robust operational safety in healthcare is in making sure that equipments are handled by qualified persons. There is a need for standardisation of availability and use of protective accessories, preventive maintenance, periodic quality assurance and a need for constant education and updating with current regulatory requirements.

Dr Mahesh Kothari, Consultant Radiologist, Reliance Hospital, Navi Mumbai added, “While an increase in radiological tests has been shown to improve overall outcome in patient care, it also increases risk of exposure to ionising radiation not only to patients but healthcare personnel as well. Though it has not yet been conclusively proven that exposure to low-dose ionising radiation due to radiology and imaging tests results in a direct increase in risk of hazardous effects, especially malignancy, indiscriminate and unnecessary use of radiation must be avoided. Current challenges in the safety aspects of radiology and imaging involve inadequate training of radiation workers; strict implementations of regulatory norms in busy radiology departments, and lack of communication with patients.”

Dr Rahul Vakharia, Consultant Radiologist, Wockhardt Hospital says, “The challenges are many folds, starting from implementing and maintaining facilities especially in smaller cities and towns. The standalone clinic in small town is the grey zone where the safety of health care worker is compromised due to lack of surveillance.”

Radiation safety: Adopting different approach for patients and personnel

Patient and personnel both are exposed to and are at risk of getting impacted with radiations but ways of approaching their safety is different which is due to various factors like stay in the vicinity, frequency of radiations etc.

Sharing his views on this, Dr Govindarajan MJ, Senior consultant and head of oncoimaging, Apollo Hospitals Bangalore explains, “Safety aspects are different for patients and personnel; while the patient and the attendant can potentially be exposed to radiation during a short stay in the vicinity, personnel spend significantly more time in the department and are more prone to radiation exposure by the nature of work and accidental exposure. Strict guidelines in the form of protective shields like lead aprons, periodic monitoring of exposure by TLD badges, and educating about possible accidental exposures are highly recommended and are being practiced in many places. Patient safety is also important requiring different methods, particularly optimising each study, in the form of avoiding unnecessary investigations, extracting maximum information possible from each study, considering alternative non-radiation imaging methods, providing protective shields to thyroid, gonads etc, assessing the risk-benefit ratio of any radiological investigation, avoiding exposure of pregnant women to radiation by sign displays and appropriate counseling, and most importantly optimising dose for each body part/size using advanced software, particularly in children.”

Dr Kothari added, “Ionising radiation due to diagnostic imaging carries different potential risks for patient and radiation worker as patient is exposed only for that particular procedure while personnel are exposed frequently. Since the effects of cumulative doses of radiation are more harmful, radiation workers must be protected with robust safety measures. Radiation safety measures need to address these separately.”

For patient safety, technicians must be trained to use as low doses of radiation as possible for diagnostic tests without compromising image quality. Appropriate communication with the radiologist and patient is essential. Use of dedicated ultra-low dose protocols in CT scans with minimum possible scan time; use of radio protective lead aprons and shields, especially for children and young adults, and display of appropriate signage to avoid accidental exposure are necessary. Radiation personnel safety is of paramount importance as workers are susceptible to much more cumulative radiation doses than patients. Appropriate construction of radiology labs to prevent leak of radiation from the tests as per norms by AERB, use of cumulative radiation dose detectors for radiation workers, rigorous radiation safety training at regular intervals and isolation and cooling off of workers who have been exposed to larger cumulative dose than prescribed are some of the measures”, he added

Preventing the direct harm: Need of the hour

Research and development, ensuring lesser effects of radiation along with maintaining the robustness of radiation safety programmes, education and training of the personnel handling the lab and also the technology are some of the aspects in handling and preventing the direct harm to the patient as well as the healthcare worker.

Dr Bhaskar suggest, “Research and development play an important role in ensuring lesser effects of radiation. Designing detectors that use low radiation but have high sensitivity and provide good quality outputs is one of the ways to protect against radiation. Strict legal enforcement of AERB guidelines (Atomic Energy Regulatory Board) regulates radiation tools and its usage. Additionally, regular monitoring of dosages must be done. Strict hospital regulation for annual check up in monitoring leakage in radiations and maintenance of personal protection devices must be conducted. Education to public and health care workers to avoid erratic usage of ionising radiation must be undertaken.”

The need of the hour is to educate the facility owner and heath care worker about the radiation hazards and its short and long term implication. The owner should provide adequate protective devices, maintain the machines and radiation area to prevent unto ward radiation exposure. Another important pillar in the radiation protection programme lies on the shoulder of clinician. Most of the clinician are not clear about the type of investigation require in the particular clinical scenario. A healthy communication between the clinician and radiologist can significantly reduce the unwanted radiation burden on patients. A conscious effect has to be made to reach to a diagnostic using non ionising modality as far as possible and perform x-ray / CT / PET CT / nuclear study only if its require”, added Dr Vakharia

Giving a slightly different perspective on radiation safety, Dr Geetha Manjunath the Founder, CEO and CTO of NIRAMAI Health Analytix suggest, “I think hospitals, diagnostic centres and even the government should encourage using radiation-free tests wherever possible.  For example, for breast cancer screening our radiologists, gynaecologists and oncologists should consider using and prescribing radiation-free Imaging solutions like thermal imaging and ultrasound imaging systems as they are safe. Ultrasound imaging is effective when the lesion is localised or there is a symptom (lump). Thermal imaging is an excellent test for localising an abnormality which can then be sent for detailed diagnostic workup. This way, only fraction of people who have a likely abnormality will be subjected to radiation-based tests as opposed to everyone – keeping patient safety as the topmost criterion.”

Angeli Misra, Founder & Director, Lifeline Laboratory explains that, “Instilling core values of health and safety must be practiced and implemented in any organisation. This must be accompanied by stringent and rigorous radioactive substances handling processes and regular audits for compliance which must be routinely reviewed, updated and implemented in all healthcare organisations, to maintain minimum exposure. Imparting comprehensive education and training in advance to personnel on occupational hazard, safe handling, emergency response, radioactive decontamination procedures and disposal process is of utmost importance. Lab technicians must strictly wear protective gear like TLD badges (loaded with cassettes to measure radiation), lead aprons, stand behind protective barriers and use other protective devices like lead curtains, etc. for safe operations and procedures. Patients too must be forewarned of the potential dangers of exposure to radiation. Additionally, regular mock drills for risk assessment must be carried out. Adequate investment in carrying out comprehensive accident investigations, improved technology and infrastructure as well as education and training must be made”

Long interventional procedures carry increased risk of radiation both to the patient and to the staff. Continuous education and awareness in limiting exposure, reducing the number of subtracted runs, use of shielding accessories etc. are crucial in interventional rooms. The patient should also be counselled for radiation risks and followed up for any visible radiation induced changes in the body.

Stressing on the ways to strengthen the robustness of radiation safety programmes, Dr Jayakrishnan added, “Ongoing safety and quality mechanisms through bodies like NABH also helps to ensure robustness of the radiation safety program. A good radiation safety program has to give equal importance for the patients, radiation workers and general public. It should include periodic audits, education and continuous refinement.”

Dr Govindarajan also suggest that, “AERB is the parent body, looking after the radiation safety aspects in India. Its regulations for health care centers are towards achieving adequate safety of both patients and personnel. Currently, the majority are compelled to follow the guidelines due to statutory requirements. Radiation safety is one of the many quality indicators in many corporate hospitals in India for the purpose of accreditation by different agencies like JCI, NABH, etc. Frequent surprise inspections by AERB personnel have an impact as well. However, the need of the hour is to create a FELT NEED among policymakers for achieving a safe radiology environment for both patients and personnel by educating, training, and focusing on the ALARA principle.”

Indirect harm: Preventing diagnostic errors

Indirect harm in the form of medical or diagnostic error is much more dangerous, common and risky as compared to direct harm. Experts believes that artificial intelligence is the best possible solution to this problem.

Sharing her views on this, Meenakshi Singh, CEO and Co-Founder, Synapsica said, “Just like cancer, diagnostic errors and communication gaps are spreading rapidly throughout the healthcare system. And despite the advancements in technology, the healthcare sector is still struggling to find an absolute solution. Almost all people are likely to experience a diagnostic error in their lifetime. Diagnostic errors are more common in primary care and low- and middle-income countries like India due to limited record-keeping systems and limited access to diagnostic facilities. The other key causes of diagnostic errors include increased workload and burnout, limited access to medical record data, limited follow-ups and cognitive issues. Nearly 7 per cent of abnormal test results are not properly communicated to patients, leading to diagnostic errors and delays. Communication gap is lethal, not just to patient care but also to the organisational performance of healthcare institutions.”

Singh believes technology to be the best solution for preventing diagnostic error. “Healthcare experts believe that artificial intelligence will be of great assistance in reducing diagnostic errors and clinical AI is already becoming an integral part of the healthcare industry. Nearly 94 per cent of Indian healthcare leaders plan to invest in AI innovations as they believe the cutting-edge technology will augment the quality of their services and patient care decision-making as it can mimic human intelligence when trained with proper datasets.”

She also added, “Numerous repetitive mundane tasks like data entry, prioritising critical studies, image sorting, allocating cases to appropriate physicians, generating reports, etc, are done manually by physicians, to be precise, radiologists. Medical imaging has become an integral part of diagnosis today, meaning, the more manual work done by radiologists, the more the delay in patient care. Also, radiologists can experience mental/visual fatigue, when they are pushed to do the same mundane tasks continuously throughout the day, resulting in missing out or overlooking minute details in images. By automating mundane tasks, like the ones mentioned above, radiologists can focus more on the clinical aspects of the case. On the other hand, automating mundane tasks using AI can help healthcare providers save a significant amount of administrative costs.”

Dr Gauri Agarwal, Co-Founder and Director of Seeds of Innocence also suggest the same. She said, “Healthcare systems can safeguard patients, enhance standards of care, and save costs by aiming to prevent common medical errors through the use of technology. To combat errors, hospitals are increasingly relying on technology and automation to relieve stress on an already strained system. Clinical mobility enables hospitals all over the world to replace manual, error-prone operations with digital solutions that improve patient identification accuracy, expedite processes, improve the quality of patient care, and improve overall visibility. Data can be delivered in real-time to healthcare staff by digitally recording information, decreasing or even eliminating errors and offering significant time savings. Clinical mobility solutions are being adopted by a growing variety of medical disciplines, including emergency department nurses, pharmacists, and lab technicians.”

Errors in Medicine, whether diagnostic, treatment related or due to lack of communication are not uncommon. While they may not be completely avoidable, every effort has to be made to reduce the occurrence of such errors and to minimise their effect. Diagnostic Radiology Departments should undertake periodic audit of errors and understand the reason why they happen and analyse the effect. This forms an important learning exercise and quality control measure. Minimising patient damage is crucial and effective communication both to the patient and to the clinical team has to be ensured. Reasons behind committing an error need to be analysed and factors that can be corrected must be attended to. Structured reporting, automated reporting of critical findings, appropriate use of machine learning etc. help to reduce number and seriousness of errors”, added Dr Jayakrishnan

Kalyani Sharma

AERB regulationradiologySafety in radiology
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