Original Article
Improving the Quality of Radiographs in Neonatal Intensive Care Unit Utilizing Educational Interventions Ashish O. Gupta, MD, FAAP1
Jeanne Rorke, RNC2
1 Division of Neonatology, Al DuPont Hospital for Children,
Wilmington, Delaware 2 Division of Neonatal-Perinatal Medicine, MedStar Georgetown University Hospital, Washington, District of Columbia
Kabir Abubakar, MD2 Address for correspondence Ashish O. Gupta, MD, FAAP, Division of Neonatology, AI DuPont Hospital for Children, 1600 Rockland road, Wilmington, DE-19803 (e-mail: [email protected]).
Am J Perinatol 2015;32:980–986.
Abstract
Keywords
► ► ► ► ►
radiographs quality improvement neonates radiation education
Objective We aimed to develop an educational tool to improve the radiograph quality, sustain this improvement overtime, and reduce the number of repeat radiographs. Study Design A three phase quality control study was conducted at a tertiary care NICU. A retrospective data collection (phase1) revealed suboptimal radiograph quality and led to an educational intervention and development of X-ray preparation checklist (primary intervention), followed by a prospective data collection for 4 months (phase 2). At the end of phase 2, interim analysis revealed a gradual decline in radiograph quality, which prompted a more comprehensive educational session with constructive feedback to the NICU staff (secondary intervention), followed by another data collection for 6 months (phase 3). Results There was a significant improvement in the quality of radiographs obtained after primary educational intervention (phase 2) compared with phase 1 (p < 0.001). During interim analysis after phase 2, radiograph quality declined but still remained significantly better than phase 1. Secondary intervention resulted in significant improvement in radiograph quality to > 95% in all domains of image quality. No radiographs were repeated in phase 3, compared with 5.8% (16/277) in phase 1. Conclusion A structured, collaborated educational intervention successfully improves the radiograph quality and decreases the need for repeat radiographs and radiation exposure in the neonates.
Background Radiographs are a very important diagnostic tool in neonatal intensive care units (NICU). Radiographs are required to formulate an accurate clinical diagnosis and interpretation of common neonatal diseases. Radiographs are also valuable for quick assessment and confirmation of appropriate placement of central catheters, endotracheal (ET), and enteric tubes in a timely fashion. Neonates, especially those born prematurely, require multiple radiographs during their neonatal course.1,2 The number of radiographs required during the neonatal period is directly proportional to the extent of prematurity
received August 23, 2014 accepted after revision January 14, 2015 published online March 4, 2015
and complexity of the underlying diseases.3,4 Some extremely premature infants may require more than 100 radiographs during their neonatal course.5 Exposure to X-rays is not benign. Radiation exposure during early childhood may increase the risk of poor outcomes including cancers.6,7 Although the carcinogenic effects of radiation exposure in the neonatal period are uncertain, premature neonates are more susceptible than adults to the chromosome-damaging effects of the radiation.8 High-quality radiographs are important to ensure accurate diagnoses, assessments, and to minimize radiation exposure.
Copyright © 2015 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0035-1547323. ISSN 0735-1631.
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Many variables can degrade the radiograph quality including poor exposure, head/body rotation, wires, and other artifacts, which may obscure the area of interest and may interfere with accurate interpretation and formulation of appropriate intervention.9,10 Poor quality of radiographs lead to repetition of radiographs and increased radiation exposure. The clinical staff at the bedside can control and minimize these factors by properly positioning the infant and removing the external artifacts from the area of interest. We hypothesized that simple educational interventions, optimization of radiography practices, and implementation of guidelines and checklists should improve the quality of radiographs in the NICU, and minimize the number of repeat radiographs and unnecessary radiation exposure. The primary purpose of our study was to analyze our current practice in the NICU, develop and implement an educational tool to improve the quality of radiographs and sustain this improvement over time without compromising the patient care. Our secondary objective was to reduce the need for repeat radiographs and the associated radiation exposure. We set a target to achieve the highest standards in each domain of image quality in more than 95% of radiographs and to reduce the number of repeat radiographs to zero. Our study was primarily focused on the improvement in the quality of radiographs by improving the factors which can be controlled by the clinical staff at the bedside.
Study Design A three-phase quality control study was conducted at a tertiary care NICU at MedStar Georgetown University Hospital (MGUH) from March 2012 to June 2013. We included plain portable radiographs performed on infants of all gestational ages and birth weights at MGUH NICU. Radiographs obtained at outside hospitals, before admission to the NICU, in specialized radiology facility or operating rooms were excluded. An improvised data collection tool was developed to score the quality of radiographs based on established radiographic principles and standardized techniques using several domains (►Table 1).11,12 Scores for the highest quality X-rays ranged from 8 to 12 depending on the type of radiograph: Chest X-ray (CXR) with ET tube—has a maximum score of 12, CXR without ET tube maximum score 10, and abdominal radiograph maximum score 8.
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A retrospective review of radiographs obtained from March 2012 to June 2012, revealed a suboptimal quality in almost all domains (phase 1). Radiographs were ordered based on the diagnostic indications determined by the primary clinical team taking care of the infants. Radiographs were evaluated by a single observer using the standardized image quality scoring tool (►Table 1). Standards for the highest quality radiographs were defined a priori. Highest quality was defined as follows: midline position of head and body, a detailed technical image quality, no cardiac monitoring leads/wires, ventilator tubing or temperature probes in the radiograph field, and arms away from the field of interest. Technical image quality was assessed by a single observer for the entire study period based on the visual analysis of the radiographs. It was scored subjectively as good, fair, or poor based on the observed exposure of the original image. Standardized radiographic parameters (radiation dose per radiograph) were used throughout the study period determined by the radiology department of our institute. An educational intervention was conducted in July 2012, including didactic sessions to the nursing staff, physicians and radiology technologists, and demonstration of good- and poor-quality radiographs (►Fig. 1) (primary intervention). Educational sessions focused on ensuring the proper positioning of the infant, shielding of gonads, and elimination of artifacts that may obscure the field of interest. Nurses were provided with a 12 point checklist to prepare the infant immediately before the radiographs were taken (►Table 2). Nurses completed an online review of the educational session which included methods to improve the quality of radiographs at bedside and review of the checklist. After initial educational interventions and implementation of recommendations, radiographs were reviewed and scored for 4 months (phase 2 data collection). An interim analysis performed at the end of phase 2 (December 2013), revealed improved but still suboptimal quality of radiographs according to our predetermined standards, and led to another more interactive educational intervention (secondary intervention). This intervention included a one-to-one review of the radiograph preparation checklist, importance of highquality radiographs and immediate on-time constructive feedback to the nurses by the primary clinical team. After secondary interventions, radiographs were reviewed again
Table 1 Data collection tool/scoring system Technical image quality
Alignment of head and body
Good: Score: 2 Fair: Score: 1 Poor: Score: 0
Well aligned: Score: 2 Minimal rotation: Score: 1 Rotated: Score: 0
Position of arms
Artifacts
Away from X-ray field: Score: 1 Covering the X-ray field: Score: 0
Leads, wires, probes, ET inline suction, vent tubing, other Away from X-ray field: Score: 1 (each) Covering the X-ray field: Score: 0 (each)
Abbreviation: ET, endotracheal. Maximum scores: Chest X-ray with ET tube: 12, Chest X-ray without ET tube: 10, Abdominal X-ray: 8. American Journal of Perinatology
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Improving the Quality of Radiographs in NICU
Improving the Quality of Radiographs in NICU
Gupta et al. Table 2 X-ray preparation checklist 1
Fig. 1 Example of good- and poor-quality radiographs.
for 6 months by the same investigator and scored for quality assessment using the same scoring system (phase 3). ►Fig. 2 depicts the Plan-Do-Study-Act (PDSA) cycle of this study, illustrating the timeline of the study and educational interventions. Data collection also included the number of repeat radiographs taken as a consequence of poor-image quality or obscured area of interest (tip of the catheter, ET tube position, etc.) because of the external artifacts or position of arms. The need for the repeat radiographs was determined by the clinical neonatology team based on whether they were able to obtain the desired information about the diagnostic indication of the radiograph. The research protocol was approved by the Georgetown University institutional review board. Statistical analysis was performed using the chi-square test, student t-test, and Fisher exact test. A p value of < 0.05 was considered significant. Mean monthly radiograph quality scores were plotted on a statistical process control chart for different type of radiographs during the duration of the study. All radiographs were reviewed and scored by a single observer during the entire study using the same scoring system.
Fig. 2 Plan-Do-Study-Act (PDSA) cycle.
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Verify X-ray order
2
Check patient ID and name
3
Gonadal shield applied
4
Head midline for chest X-rays (CXR)
5
Arms secured to side
6
Chest leads attached to arms/side of the chest
7
Wires moved away from the X-ray field
8
ET tube suction/ventilator tubes out of X-ray field
9
Check ET marking at gum prior to CXR
10
Temp probe moved to side/disconnected
11
Remove gel pads or water heater blankets
12
Nothing on top of incubator within X-ray field
Abbreviations: CXR, chest X-rays; ET, endotracheal.
Results Of the 974 radiographs reviewed during the study period, 285 were performed in phase 1, 279 in phase 2, 77 during interim analysis, and 333 in phase 3. ►Table 3 shows the number of different types of radiographs obtained in all phases. A higher number of abdominal radiographs were performed during phase 1 (39%) and phase 3 (34%) as compared to phase 2 (24%). Number of CXR with ET tube placement which carried the highest quality score (12), were similar in all the three phases, except for a higher number of CXR with ET tubes that were performed during interim analysis period (51%). ►Table 4 illustrates the image quality scores for all domains in different phases of the study. Head position was only scored for CXRs. Phase 1 retrospective review of data revealed less-than-optimal quality of radiographs in all
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Table 3 Type of radiographs in different phases Type of radiographs
Phase 1
Phase 2
Interim analysis
Phase 3
N ¼ 285, n (%)
N ¼ 279, n (%)
N ¼ 77, n (%)
N ¼ 333, n (%)
CXR with ET tube
81 (28)
86 (31)
39 (51)
102 (31)
CXR without ET tube
94 (33)
126 (45)
27 (35)
118 (35)
Abdominal X-ray
110 (39)
67 (24)
11 (14)
113 (34)
Abbreviations: CXR, chest X-rays; ET, endotracheal.
Criteria
Phase 1 % (number/total)
Phase 2 % (number/total)
Interim analysis % (number/total)
Phase 3 % (number/total)
Technical image quality
95 (271/285)
99 (276/279)
100 (77/77)
99 (329/333)
Head: centered or minimal rotation
46 (80/175)
95 (202/212)
81 (54/66)
97a (213/220)
Body: centered or minimal rotation
91 (259/285)
99 (276/279)
97 (75/77)
100 (333/333)
Away from X-ray field
96 (277/285)
100 (279/279)
100 (77/77)
100 (333/333)
Arms
a
a
a
Chest leads
53 (151/285)
95 (265/279)
84 (65/77)
97a (323/333)
Wires
47 (134/285)
90a (251/279)
84a (65/77)
95a (316/333)
a
a
Temp probe
75 (214/285)
98 (273/279)
84 (65/77)
97a (323/333)
ET tube inline suction
64 (52/81)
96a (83/86)
85a (33/39)
97a (99/102)
Ventilator tubing
71 (58/81)
100a (86/86)
82 (32/39)
98a (100/102)
Other artifacts
73 (208/285)
91a (254/279)
87a (67/77)
95a (316/333)
Abbreviation: ET, endotracheal. a Denotes p < 0.001 as compared with phase I.
domains, except the technical image quality (95%) and arms being away from the field of interest (96%). After primary intervention, there was a significant improvement in quality for all types of radiographs in phase 2 (p < 0.001) and in all domains as compared with phase 1(►Table 4, ►Fig. 3). Interim analysis of 77 radiographs at the end of phase 2 revealed a decline in quality of radiographs in some domains, but still remained superior to phase 1 (►Table 4, ►Fig. 3). These suboptimal scores led to a secondary intervention with a more aggressive educational approach and regular constructive feedback to the nurses by the primary clinical neonatology team. Phase 3 data revealed significant improvement in the quality of all types of radiographs as compared with phase 1 (p < 0.001) and this improvement was sustained for the 6 months analyzed (►Fig. 3). ►Fig. 3 shows the statistical process control chart of monthly mean image quality scores for different types of radiographs during the entire study period. Mean scores improved significantly from phase 1 to phase 2 and were sustained during phase 3 (p < 0.001). A slightly diminished score was noted during interim analysis, but it remained significantly better than phase 1 for all the type of radiographs (p < 0.01). There was a significant decrease in the number of repeat radiographs noted after implementation of educational interventions. In phase 1, 16 radiographs (5.6%) were repeated as a consequence of poor quality of the radiographs or obscured field of interest. Only one radiograph was repeated in phase 2 (0.36%)
and two during interim analysis (2.6%). After the secondary intervention, no repeat radiographs were needed in phase 3 over the period of 6 months (0%) (►Fig. 4).
Discussion Radiographs are considered an indispensable tool in NICUs and play a significant role in accurate clinical diagnosis and assessment of appropriate placement of central catheters, ET, and other tubes in a timely manner. Radiographs should be of the highest quality to ensure the best utilization of this exceptional but not so benign technology. Although ultrasound can be used to evaluate the placement of central catheters13,14 and ET tubes,15 it is not feasible to readily use it in every clinical setting. Many variables can degrade the radiograph quality including poor exposure, head/body rotation, wires, and other artifacts, which may obscure the area of interest and lead to repetition of radiographs with increased radiation exposure. The clinical staff at the bedside can control and minimize these factors by properly positioning the infant and removing external artifacts from the area of interest. We examined the practices and procedure for taking radiographs in our NICU and implemented an educational tool to improve the quality of radiographs by providing staff with guidelines and checklists that ensure that the patient is optimally positioned and all artifacts are removed from the American Journal of Perinatology
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Table 4 Review of radiograph quality: comparison of phases
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Phase 1
Phase 2
Int. Anal.
Primary Intervention
Phase 3
Secondary Intervention
12
CXR with ET tube
11 10 9 8 7 6 5
10 9 8 7 6 5 4
8
Abdominal x-ray
7
6
5
4 Mar-12
Apr
May
June
Jul
Aug
Sep
Oct
Nov
Dec
Jan-13
Feb
Mar
Apr
May
Jun
Fig. 3 Statistical process control chart: Comparison of monthly mean image quality scores for different type of radiographs. CXR, chest X-ray; ET, endotracheal.
radiograph field. We provided additional educational interventions periodically to sustain this improvement over time and showed a significant improvement in the quality of radiographs and a decrease in repeat radiographs obtained because of poor quality. The impact of successfully implemented educational interventions has been well established.16–18 Our results are
Fig. 4 Number of repeat radiographs in different phases.
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consistent with previous findings, but this is the first quality control study to review a large number of radiographs (964) over a period of more than 1 year. Health care providers in our NICU expressed concern regarding a significant number of poor-quality images. Retrospective review of data showed there were several areas of concern that need improvement. An educational session targeting these areas of concern led to significant improvement in standardized image quality scores which was sustained for 4 months (phase 2). There was a slight decline in scores with two repeat radiographs immediately after the end of phase 2, this led to a more comprehensive secondary intervention, which resulted in a sustained significant improvement for 6 months and no radiographs were repeated during this period. Loovere et al described the utility of neonatal radiograph audit and educational intervention to improve the quality of radiographs.10 A small number of radiographs were reviewed for only 1 week, after 1 month (n ¼ 76), and 1 year (n ¼ 93) of primary intervention. In this study, they also demonstrated improvement in the completeness of radiograph requisition and medical documentation. In our institute, we use a computerized physician order entry system which reduces the
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CXR without ET tube
Mean radiograph quality score
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likelihood of errors in radiograph requisitions and we reviewed a larger number of radiographs consistently every month for more than 1 year. Frequent audits and consistent feedback may lead to long-term improvement in radiograph quality. Checklists have been demonstrated to be valuable tools for quality assurance, minimizing errors, and improving safety in several areas, including aviation and surgical procedures.19 We developed a simple, comprehensive, and generally applicable radiograph preparation checklist, which emphasizes patient identification and precise preparation of the infant to achieve the highest radiograph quality and takes less than 2 minutes to complete. In our NICU, a nurse has to be present when a radiograph is being taken by the radiology technologist to make sure the infant is appropriately secured and stable although they do not have to hold the infant for the procedure. For sterile procedures, such as, umbilical catheter or other central line placement, nurses prepare and position the infant in advance before the procedure is started so the sterile field can be maintained after the procedure while radiograph is being taken. Midline position of the head and body on the radiograph is critical for the accurate assessment of ET tube placement. Developmental positioning aids can play an important role in maintaining the midline position of head and body and prevent movement of the extremities. This may avoid the need for an assistant to hold the infant during the radiograph and unnecessary radiation exposure to the staff. In our study, only 46% of radiographs had centered or minimal rotation of head in phase 1, which significantly improved to 95% in phase 2 and 97% in phase 3. Elimination of artifacts from the field of interest is equally important; chest leads can be placed on side of the chest or arms, wires, and tubing should be moved away and the temperature probe should be placed on the side of the abdominal wall, to provide the best possible results. Educational sessions decreased the number of obscured images from nearly 50% in phase 1 to < 5% in phase 3. Simulation studies have shown that frequent refresher training should be considered to prevent the declining skills.20 Similarly, it is essential to reinforce training every 4 to 6 months including review of the checklist and consistent feedback to the nurses to maintain the optimum image quality. In our study, a downward trend in the quality scores was noted at the end of phase 2 and phase 3. These low scores may also be attributed to the addition of new nursing staff. It is essential to minimize the radiation exposure while maintaining the optimum image quality. Neonates are at higher risk of radiation-induced complications because of increased neonatal radiosensitivity and long life expectancy after exposure.8 Although it is difficult to predict the carcinogenic effects of radiation exposure in neonates, cumulative effects of these radiations are a major concern.21 Repeat radiographs unnecessarily irradiate infants, and also create delays in the clinical management of critically ill infants. Our study demonstrated that adherence to the checklist and guidelines significantly decrease the number of repeat radiographs which were required as a consequence of poor-image quality and obscured field of interest. There was a significant decline in the number of repeat
Gupta et al.
radiographs after educational interventions, from 5.6% (16/285) in phase 1 to 0% (0/333) in phase 3. To prevent possible interobserver bias, a single observer reviewed all radiographs during the entire study period, utilizing the same standardized image-quality scoring system. We speculate that the sustained improvement of a longer duration in phase 3 was primarily a consequence of regular constructive feedback and unrelenting diligence of nurses to precisely follow the checklist when preparing the infant for radiographs. One of the limitations of our study was that we did not collect data regarding gonadal shielding. Placement of gonadal shield was a step in our checklist, but it was excluded from the scoring system because they were not uniformly used. Radiograph quality including the technical image quality was determined by the investigator based on the visual analysis of the exposure. Radiologists or radiation physicist could have quantified the exposure and the amount of radiations. We did not analyze the data for different nursing shifts, though the improvement was noted in > 95% of radiographs in phase 3. In summary, it is imperative to ensure the midline positioning of head and body, good technical image quality, and removal of chest leads/wires/tubing/probes and other artifacts from the area of interest, to accomplish the highest standards of radiographs quality and minimize the number of repeat radiographs. The guidelines and checklist used in this study are not an exhaustive list of all interventions that can be done to minimize radiation exposure in neonates. Each institution should in consultation with the radiology department develop strict technical exposure parameters to be used that minimize radiation exposure for different types of neonatal radiographs. To this end, the American College of Radiology has developed a new Image Gently campaign “Back to Basics” initiative with online teaching materials, checklists, and practice quality improvement projects to help providers strengthen radiation protection when performing X-ray examinations on children with particular emphasis on the need for a standardized approach by measuring patient body size and developing technique charts.22
Conclusions Our study demonstrated that a structured, collaborative educational intervention appears to be successful in improving the quality of radiographs and decreasing the number of repeat radiographs in NICU. In conjunction with following the checklist and recommendations, constant constructive feedback is crucial to ascertain the highest quality of radiographs. Reinforcement training to the nursing and radiology staff is required at regular interval of 4 to 6 months to maintain the optimum radiograph quality.
Funding Source No external funding was secured for this study. Financial Disclosure The authors have no financial relationships relevant to this article to disclose.
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Conflicts of Interest The authors declare no conflicts of interest to disclose.
10 Loovere L, Boyle EM, Blatz S, Bowslaugh M, Kereliuk M, Paes B.
11
Acknowledgments A. O. G. conceptualized and designed the study, collected data, performed the analyses, and drafted the initial manuscript. J. R. assisted in developing data collection tool, educated the nursing staff, assisted in data collection, and analysis. K. A. coordinated and supervised data collection and analysis and critically reviewed the manuscript. The final manuscript was approved by all the authors.
12 13
14
15
References
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1 Sutton PM, Arthur RJ, Taylor C, Stringer MD. Ionising radiation
2
3
4
5 6
7
8
9
from diagnostic x rays in very low birthweight babies. Arch Dis Child Fetal Neonatal Ed 1998;78(3):F227–F229 Wilson-Costello D, Rao PS, Morrison S, Hack M. Radiation exposure from diagnostic radiographs in extremely low birth weight infants. Pediatrics 1996;97(3):369–374 Donadieu J, Zeghnoun A, Roudier C, et al. Cumulative effective doses delivered by radiographs to preterm infants in a neonatal intensive care unit. Pediatrics 2006;117(3):882–888 Arad I, Simanovsky N, Braunstein R. Exposure of extremely low birth weight infants to diagnostic X-Rays: a longitudinal study. Acta Paediatr 2009;98(2):266–269 Vachharajani A, Vachharajani NA, Najaf T. Neonatal radiation exposure. Neo Rev 2013;14(4):e190–e197 Berrington de González A, Darby S. Risk of cancer from diagnostic X-rays: estimates for the UK and 14 other countries. Lancet 2004; 363(9406):345–351 Hall P, Adami HO, Trichopoulos D, et al. Effect of low doses of ionising radiation in infancy on cognitive function in adulthood: Swedish population based cohort study. BMJ 2004; 328(7430):19 Dougeni ED, Delis HB, Karatza AA, et al. Dose and image quality optimization in neonatal radiography. Br J Radiol 2007;80(958): 807–815 Hellwig BJ, Wilson B. Quality improvement related to radiation safety chest radiography in the NICU. Radiol Manage 2013;35(2): 18–23, quiz 24–25
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18
19
20
21
22
Quality improvement in radiography in a neonatal intensive care unit. Can Assoc Radiol J 2008;59(4):197–202 Ballinger PW, Frank ED. Merrill’s Atlas of Radiographic Position and Radiologic Procedure. Vol 3. St. Louis, MO: Mosby; 2003 Meerstadt PWD, Gyll C. Manual of Neonatal emergency X-ray Interpretation. London (GB): WB Saunders; 1994:1–6 Simanovsky N, Ofek-Shlomai N, Rozovsky K, Ergaz-Shaltiel Z, Hiller N, Bar-Oz B. Umbilical venous catheter position: evaluation by ultrasound. Eur Radiol 2011;21(9):1882–1886 Katheria AC, Fleming SE, Kim JH. A randomized controlled trial of ultrasound-guided peripherally inserted central catheters compared with standard radiograph in neonates. J Perinatol 2013; 33(10):791–794 Dennington D, Vali P, Finer NN, Kim JH. Ultrasound confirmation of endotracheal tube position in neonates. Neonatology 2012; 102(3):185–189 Bussières AE, Sales AE, Ramsay T, Hilles SM, Grimshaw JM. Impact of imaging guidelines on Xray use among American provider network chiropractors: interrupted time series analysis. Spine J 2014;14(8):1501–1509 Cobo ME, Vicente A, Corres J, Royuela A, Zamora J. Implementing a guideline for the request of chest and abdominal x-rays in nontrauma pathologic conditions in an ED. Am J Emerg Med 2009; 27(1):76–83 McWhirter E, Yogendran G, Wright F, Pharm GD, Clemons M; Cancer Care Ontario Practice Guidelines Initiative. Baseline radiological staging in primary breast cancer: impact of educational interventions on adherence to published guidelines. J Eval Clin Pract 2007;13(4):647–650 John SD, Moore QT, Herrmann T, et al. The Image Gently pediatric digital radiography safety checklist: tools for improving pediatric radiography. J Am Coll Radiol 2013;10(10):781–788 Thomas SM, Burch W, Kuehnle SE, Flood RG, Scalzo AJ, Gerard JM. Simulation training for pediatric residents on central venous catheter placement: a pilot study. Pediatr Crit Care Med 2013; 14(9):e416–e423 United Nations Scientific Committee on the Effects of Atomic RadiationSources and effects of ionizing radiation. Available at: http://www.unscear.org/docs/reports/2008/11-80076_Report_ 2008_Annex_D.pdf. Accessed September 12, 2012 Don S, Macdougall R, Strauss K, et al. Image gently campaign back to basics initiative: ten steps to help manage radiation dose in pediatric digital radiography. Am J Roentgenol 2013;200(5): W431–6
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Improving the Quality of Radiographs in Neonatal Intensive Care Unit Utilizing Educational Interventions Ashish O. Gupta, MD, FAAP1
Jeanne Rorke, RNC2
1 Division of Neonatology, Al DuPont Hospital for Children,
Wilmington, Delaware 2 Division of Neonatal-Perinatal Medicine, MedStar Georgetown University Hospital, Washington, District of Columbia
Kabir Abubakar, MD2 Address for correspondence Ashish O. Gupta, MD, FAAP, Division of Neonatology, AI DuPont Hospital for Children, 1600 Rockland road, Wilmington, DE-19803 (e-mail: [email protected]).
Am J Perinatol 2015;32:980–986.
Abstract
Keywords
► ► ► ► ►
radiographs quality improvement neonates radiation education
Objective We aimed to develop an educational tool to improve the radiograph quality, sustain this improvement overtime, and reduce the number of repeat radiographs. Study Design A three phase quality control study was conducted at a tertiary care NICU. A retrospective data collection (phase1) revealed suboptimal radiograph quality and led to an educational intervention and development of X-ray preparation checklist (primary intervention), followed by a prospective data collection for 4 months (phase 2). At the end of phase 2, interim analysis revealed a gradual decline in radiograph quality, which prompted a more comprehensive educational session with constructive feedback to the NICU staff (secondary intervention), followed by another data collection for 6 months (phase 3). Results There was a significant improvement in the quality of radiographs obtained after primary educational intervention (phase 2) compared with phase 1 (p < 0.001). During interim analysis after phase 2, radiograph quality declined but still remained significantly better than phase 1. Secondary intervention resulted in significant improvement in radiograph quality to > 95% in all domains of image quality. No radiographs were repeated in phase 3, compared with 5.8% (16/277) in phase 1. Conclusion A structured, collaborated educational intervention successfully improves the radiograph quality and decreases the need for repeat radiographs and radiation exposure in the neonates.
Background Radiographs are a very important diagnostic tool in neonatal intensive care units (NICU). Radiographs are required to formulate an accurate clinical diagnosis and interpretation of common neonatal diseases. Radiographs are also valuable for quick assessment and confirmation of appropriate placement of central catheters, endotracheal (ET), and enteric tubes in a timely fashion. Neonates, especially those born prematurely, require multiple radiographs during their neonatal course.1,2 The number of radiographs required during the neonatal period is directly proportional to the extent of prematurity
received August 23, 2014 accepted after revision January 14, 2015 published online March 4, 2015
and complexity of the underlying diseases.3,4 Some extremely premature infants may require more than 100 radiographs during their neonatal course.5 Exposure to X-rays is not benign. Radiation exposure during early childhood may increase the risk of poor outcomes including cancers.6,7 Although the carcinogenic effects of radiation exposure in the neonatal period are uncertain, premature neonates are more susceptible than adults to the chromosome-damaging effects of the radiation.8 High-quality radiographs are important to ensure accurate diagnoses, assessments, and to minimize radiation exposure.
Copyright © 2015 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0035-1547323. ISSN 0735-1631.
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Many variables can degrade the radiograph quality including poor exposure, head/body rotation, wires, and other artifacts, which may obscure the area of interest and may interfere with accurate interpretation and formulation of appropriate intervention.9,10 Poor quality of radiographs lead to repetition of radiographs and increased radiation exposure. The clinical staff at the bedside can control and minimize these factors by properly positioning the infant and removing the external artifacts from the area of interest. We hypothesized that simple educational interventions, optimization of radiography practices, and implementation of guidelines and checklists should improve the quality of radiographs in the NICU, and minimize the number of repeat radiographs and unnecessary radiation exposure. The primary purpose of our study was to analyze our current practice in the NICU, develop and implement an educational tool to improve the quality of radiographs and sustain this improvement over time without compromising the patient care. Our secondary objective was to reduce the need for repeat radiographs and the associated radiation exposure. We set a target to achieve the highest standards in each domain of image quality in more than 95% of radiographs and to reduce the number of repeat radiographs to zero. Our study was primarily focused on the improvement in the quality of radiographs by improving the factors which can be controlled by the clinical staff at the bedside.
Study Design A three-phase quality control study was conducted at a tertiary care NICU at MedStar Georgetown University Hospital (MGUH) from March 2012 to June 2013. We included plain portable radiographs performed on infants of all gestational ages and birth weights at MGUH NICU. Radiographs obtained at outside hospitals, before admission to the NICU, in specialized radiology facility or operating rooms were excluded. An improvised data collection tool was developed to score the quality of radiographs based on established radiographic principles and standardized techniques using several domains (►Table 1).11,12 Scores for the highest quality X-rays ranged from 8 to 12 depending on the type of radiograph: Chest X-ray (CXR) with ET tube—has a maximum score of 12, CXR without ET tube maximum score 10, and abdominal radiograph maximum score 8.
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A retrospective review of radiographs obtained from March 2012 to June 2012, revealed a suboptimal quality in almost all domains (phase 1). Radiographs were ordered based on the diagnostic indications determined by the primary clinical team taking care of the infants. Radiographs were evaluated by a single observer using the standardized image quality scoring tool (►Table 1). Standards for the highest quality radiographs were defined a priori. Highest quality was defined as follows: midline position of head and body, a detailed technical image quality, no cardiac monitoring leads/wires, ventilator tubing or temperature probes in the radiograph field, and arms away from the field of interest. Technical image quality was assessed by a single observer for the entire study period based on the visual analysis of the radiographs. It was scored subjectively as good, fair, or poor based on the observed exposure of the original image. Standardized radiographic parameters (radiation dose per radiograph) were used throughout the study period determined by the radiology department of our institute. An educational intervention was conducted in July 2012, including didactic sessions to the nursing staff, physicians and radiology technologists, and demonstration of good- and poor-quality radiographs (►Fig. 1) (primary intervention). Educational sessions focused on ensuring the proper positioning of the infant, shielding of gonads, and elimination of artifacts that may obscure the field of interest. Nurses were provided with a 12 point checklist to prepare the infant immediately before the radiographs were taken (►Table 2). Nurses completed an online review of the educational session which included methods to improve the quality of radiographs at bedside and review of the checklist. After initial educational interventions and implementation of recommendations, radiographs were reviewed and scored for 4 months (phase 2 data collection). An interim analysis performed at the end of phase 2 (December 2013), revealed improved but still suboptimal quality of radiographs according to our predetermined standards, and led to another more interactive educational intervention (secondary intervention). This intervention included a one-to-one review of the radiograph preparation checklist, importance of highquality radiographs and immediate on-time constructive feedback to the nurses by the primary clinical team. After secondary interventions, radiographs were reviewed again
Table 1 Data collection tool/scoring system Technical image quality
Alignment of head and body
Good: Score: 2 Fair: Score: 1 Poor: Score: 0
Well aligned: Score: 2 Minimal rotation: Score: 1 Rotated: Score: 0
Position of arms
Artifacts
Away from X-ray field: Score: 1 Covering the X-ray field: Score: 0
Leads, wires, probes, ET inline suction, vent tubing, other Away from X-ray field: Score: 1 (each) Covering the X-ray field: Score: 0 (each)
Abbreviation: ET, endotracheal. Maximum scores: Chest X-ray with ET tube: 12, Chest X-ray without ET tube: 10, Abdominal X-ray: 8. American Journal of Perinatology
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Gupta et al. Table 2 X-ray preparation checklist 1
Fig. 1 Example of good- and poor-quality radiographs.
for 6 months by the same investigator and scored for quality assessment using the same scoring system (phase 3). ►Fig. 2 depicts the Plan-Do-Study-Act (PDSA) cycle of this study, illustrating the timeline of the study and educational interventions. Data collection also included the number of repeat radiographs taken as a consequence of poor-image quality or obscured area of interest (tip of the catheter, ET tube position, etc.) because of the external artifacts or position of arms. The need for the repeat radiographs was determined by the clinical neonatology team based on whether they were able to obtain the desired information about the diagnostic indication of the radiograph. The research protocol was approved by the Georgetown University institutional review board. Statistical analysis was performed using the chi-square test, student t-test, and Fisher exact test. A p value of < 0.05 was considered significant. Mean monthly radiograph quality scores were plotted on a statistical process control chart for different type of radiographs during the duration of the study. All radiographs were reviewed and scored by a single observer during the entire study using the same scoring system.
Fig. 2 Plan-Do-Study-Act (PDSA) cycle.
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Verify X-ray order
2
Check patient ID and name
3
Gonadal shield applied
4
Head midline for chest X-rays (CXR)
5
Arms secured to side
6
Chest leads attached to arms/side of the chest
7
Wires moved away from the X-ray field
8
ET tube suction/ventilator tubes out of X-ray field
9
Check ET marking at gum prior to CXR
10
Temp probe moved to side/disconnected
11
Remove gel pads or water heater blankets
12
Nothing on top of incubator within X-ray field
Abbreviations: CXR, chest X-rays; ET, endotracheal.
Results Of the 974 radiographs reviewed during the study period, 285 were performed in phase 1, 279 in phase 2, 77 during interim analysis, and 333 in phase 3. ►Table 3 shows the number of different types of radiographs obtained in all phases. A higher number of abdominal radiographs were performed during phase 1 (39%) and phase 3 (34%) as compared to phase 2 (24%). Number of CXR with ET tube placement which carried the highest quality score (12), were similar in all the three phases, except for a higher number of CXR with ET tubes that were performed during interim analysis period (51%). ►Table 4 illustrates the image quality scores for all domains in different phases of the study. Head position was only scored for CXRs. Phase 1 retrospective review of data revealed less-than-optimal quality of radiographs in all
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Table 3 Type of radiographs in different phases Type of radiographs
Phase 1
Phase 2
Interim analysis
Phase 3
N ¼ 285, n (%)
N ¼ 279, n (%)
N ¼ 77, n (%)
N ¼ 333, n (%)
CXR with ET tube
81 (28)
86 (31)
39 (51)
102 (31)
CXR without ET tube
94 (33)
126 (45)
27 (35)
118 (35)
Abdominal X-ray
110 (39)
67 (24)
11 (14)
113 (34)
Abbreviations: CXR, chest X-rays; ET, endotracheal.
Criteria
Phase 1 % (number/total)
Phase 2 % (number/total)
Interim analysis % (number/total)
Phase 3 % (number/total)
Technical image quality
95 (271/285)
99 (276/279)
100 (77/77)
99 (329/333)
Head: centered or minimal rotation
46 (80/175)
95 (202/212)
81 (54/66)
97a (213/220)
Body: centered or minimal rotation
91 (259/285)
99 (276/279)
97 (75/77)
100 (333/333)
Away from X-ray field
96 (277/285)
100 (279/279)
100 (77/77)
100 (333/333)
Arms
a
a
a
Chest leads
53 (151/285)
95 (265/279)
84 (65/77)
97a (323/333)
Wires
47 (134/285)
90a (251/279)
84a (65/77)
95a (316/333)
a
a
Temp probe
75 (214/285)
98 (273/279)
84 (65/77)
97a (323/333)
ET tube inline suction
64 (52/81)
96a (83/86)
85a (33/39)
97a (99/102)
Ventilator tubing
71 (58/81)
100a (86/86)
82 (32/39)
98a (100/102)
Other artifacts
73 (208/285)
91a (254/279)
87a (67/77)
95a (316/333)
Abbreviation: ET, endotracheal. a Denotes p < 0.001 as compared with phase I.
domains, except the technical image quality (95%) and arms being away from the field of interest (96%). After primary intervention, there was a significant improvement in quality for all types of radiographs in phase 2 (p < 0.001) and in all domains as compared with phase 1(►Table 4, ►Fig. 3). Interim analysis of 77 radiographs at the end of phase 2 revealed a decline in quality of radiographs in some domains, but still remained superior to phase 1 (►Table 4, ►Fig. 3). These suboptimal scores led to a secondary intervention with a more aggressive educational approach and regular constructive feedback to the nurses by the primary clinical neonatology team. Phase 3 data revealed significant improvement in the quality of all types of radiographs as compared with phase 1 (p < 0.001) and this improvement was sustained for the 6 months analyzed (►Fig. 3). ►Fig. 3 shows the statistical process control chart of monthly mean image quality scores for different types of radiographs during the entire study period. Mean scores improved significantly from phase 1 to phase 2 and were sustained during phase 3 (p < 0.001). A slightly diminished score was noted during interim analysis, but it remained significantly better than phase 1 for all the type of radiographs (p < 0.01). There was a significant decrease in the number of repeat radiographs noted after implementation of educational interventions. In phase 1, 16 radiographs (5.6%) were repeated as a consequence of poor quality of the radiographs or obscured field of interest. Only one radiograph was repeated in phase 2 (0.36%)
and two during interim analysis (2.6%). After the secondary intervention, no repeat radiographs were needed in phase 3 over the period of 6 months (0%) (►Fig. 4).
Discussion Radiographs are considered an indispensable tool in NICUs and play a significant role in accurate clinical diagnosis and assessment of appropriate placement of central catheters, ET, and other tubes in a timely manner. Radiographs should be of the highest quality to ensure the best utilization of this exceptional but not so benign technology. Although ultrasound can be used to evaluate the placement of central catheters13,14 and ET tubes,15 it is not feasible to readily use it in every clinical setting. Many variables can degrade the radiograph quality including poor exposure, head/body rotation, wires, and other artifacts, which may obscure the area of interest and lead to repetition of radiographs with increased radiation exposure. The clinical staff at the bedside can control and minimize these factors by properly positioning the infant and removing external artifacts from the area of interest. We examined the practices and procedure for taking radiographs in our NICU and implemented an educational tool to improve the quality of radiographs by providing staff with guidelines and checklists that ensure that the patient is optimally positioned and all artifacts are removed from the American Journal of Perinatology
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Table 4 Review of radiograph quality: comparison of phases
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Phase 1
Phase 2
Int. Anal.
Primary Intervention
Phase 3
Secondary Intervention
12
CXR with ET tube
11 10 9 8 7 6 5
10 9 8 7 6 5 4
8
Abdominal x-ray
7
6
5
4 Mar-12
Apr
May
June
Jul
Aug
Sep
Oct
Nov
Dec
Jan-13
Feb
Mar
Apr
May
Jun
Fig. 3 Statistical process control chart: Comparison of monthly mean image quality scores for different type of radiographs. CXR, chest X-ray; ET, endotracheal.
radiograph field. We provided additional educational interventions periodically to sustain this improvement over time and showed a significant improvement in the quality of radiographs and a decrease in repeat radiographs obtained because of poor quality. The impact of successfully implemented educational interventions has been well established.16–18 Our results are
Fig. 4 Number of repeat radiographs in different phases.
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consistent with previous findings, but this is the first quality control study to review a large number of radiographs (964) over a period of more than 1 year. Health care providers in our NICU expressed concern regarding a significant number of poor-quality images. Retrospective review of data showed there were several areas of concern that need improvement. An educational session targeting these areas of concern led to significant improvement in standardized image quality scores which was sustained for 4 months (phase 2). There was a slight decline in scores with two repeat radiographs immediately after the end of phase 2, this led to a more comprehensive secondary intervention, which resulted in a sustained significant improvement for 6 months and no radiographs were repeated during this period. Loovere et al described the utility of neonatal radiograph audit and educational intervention to improve the quality of radiographs.10 A small number of radiographs were reviewed for only 1 week, after 1 month (n ¼ 76), and 1 year (n ¼ 93) of primary intervention. In this study, they also demonstrated improvement in the completeness of radiograph requisition and medical documentation. In our institute, we use a computerized physician order entry system which reduces the
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CXR without ET tube
Mean radiograph quality score
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likelihood of errors in radiograph requisitions and we reviewed a larger number of radiographs consistently every month for more than 1 year. Frequent audits and consistent feedback may lead to long-term improvement in radiograph quality. Checklists have been demonstrated to be valuable tools for quality assurance, minimizing errors, and improving safety in several areas, including aviation and surgical procedures.19 We developed a simple, comprehensive, and generally applicable radiograph preparation checklist, which emphasizes patient identification and precise preparation of the infant to achieve the highest radiograph quality and takes less than 2 minutes to complete. In our NICU, a nurse has to be present when a radiograph is being taken by the radiology technologist to make sure the infant is appropriately secured and stable although they do not have to hold the infant for the procedure. For sterile procedures, such as, umbilical catheter or other central line placement, nurses prepare and position the infant in advance before the procedure is started so the sterile field can be maintained after the procedure while radiograph is being taken. Midline position of the head and body on the radiograph is critical for the accurate assessment of ET tube placement. Developmental positioning aids can play an important role in maintaining the midline position of head and body and prevent movement of the extremities. This may avoid the need for an assistant to hold the infant during the radiograph and unnecessary radiation exposure to the staff. In our study, only 46% of radiographs had centered or minimal rotation of head in phase 1, which significantly improved to 95% in phase 2 and 97% in phase 3. Elimination of artifacts from the field of interest is equally important; chest leads can be placed on side of the chest or arms, wires, and tubing should be moved away and the temperature probe should be placed on the side of the abdominal wall, to provide the best possible results. Educational sessions decreased the number of obscured images from nearly 50% in phase 1 to < 5% in phase 3. Simulation studies have shown that frequent refresher training should be considered to prevent the declining skills.20 Similarly, it is essential to reinforce training every 4 to 6 months including review of the checklist and consistent feedback to the nurses to maintain the optimum image quality. In our study, a downward trend in the quality scores was noted at the end of phase 2 and phase 3. These low scores may also be attributed to the addition of new nursing staff. It is essential to minimize the radiation exposure while maintaining the optimum image quality. Neonates are at higher risk of radiation-induced complications because of increased neonatal radiosensitivity and long life expectancy after exposure.8 Although it is difficult to predict the carcinogenic effects of radiation exposure in neonates, cumulative effects of these radiations are a major concern.21 Repeat radiographs unnecessarily irradiate infants, and also create delays in the clinical management of critically ill infants. Our study demonstrated that adherence to the checklist and guidelines significantly decrease the number of repeat radiographs which were required as a consequence of poor-image quality and obscured field of interest. There was a significant decline in the number of repeat
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radiographs after educational interventions, from 5.6% (16/285) in phase 1 to 0% (0/333) in phase 3. To prevent possible interobserver bias, a single observer reviewed all radiographs during the entire study period, utilizing the same standardized image-quality scoring system. We speculate that the sustained improvement of a longer duration in phase 3 was primarily a consequence of regular constructive feedback and unrelenting diligence of nurses to precisely follow the checklist when preparing the infant for radiographs. One of the limitations of our study was that we did not collect data regarding gonadal shielding. Placement of gonadal shield was a step in our checklist, but it was excluded from the scoring system because they were not uniformly used. Radiograph quality including the technical image quality was determined by the investigator based on the visual analysis of the exposure. Radiologists or radiation physicist could have quantified the exposure and the amount of radiations. We did not analyze the data for different nursing shifts, though the improvement was noted in > 95% of radiographs in phase 3. In summary, it is imperative to ensure the midline positioning of head and body, good technical image quality, and removal of chest leads/wires/tubing/probes and other artifacts from the area of interest, to accomplish the highest standards of radiographs quality and minimize the number of repeat radiographs. The guidelines and checklist used in this study are not an exhaustive list of all interventions that can be done to minimize radiation exposure in neonates. Each institution should in consultation with the radiology department develop strict technical exposure parameters to be used that minimize radiation exposure for different types of neonatal radiographs. To this end, the American College of Radiology has developed a new Image Gently campaign “Back to Basics” initiative with online teaching materials, checklists, and practice quality improvement projects to help providers strengthen radiation protection when performing X-ray examinations on children with particular emphasis on the need for a standardized approach by measuring patient body size and developing technique charts.22
Conclusions Our study demonstrated that a structured, collaborative educational intervention appears to be successful in improving the quality of radiographs and decreasing the number of repeat radiographs in NICU. In conjunction with following the checklist and recommendations, constant constructive feedback is crucial to ascertain the highest quality of radiographs. Reinforcement training to the nursing and radiology staff is required at regular interval of 4 to 6 months to maintain the optimum radiograph quality.
Funding Source No external funding was secured for this study. Financial Disclosure The authors have no financial relationships relevant to this article to disclose.
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Conflicts of Interest The authors declare no conflicts of interest to disclose.
10 Loovere L, Boyle EM, Blatz S, Bowslaugh M, Kereliuk M, Paes B.
11
Acknowledgments A. O. G. conceptualized and designed the study, collected data, performed the analyses, and drafted the initial manuscript. J. R. assisted in developing data collection tool, educated the nursing staff, assisted in data collection, and analysis. K. A. coordinated and supervised data collection and analysis and critically reviewed the manuscript. The final manuscript was approved by all the authors.
12 13
14
15
References
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1 Sutton PM, Arthur RJ, Taylor C, Stringer MD. Ionising radiation
2
3
4
5 6
7
8
9
from diagnostic x rays in very low birthweight babies. Arch Dis Child Fetal Neonatal Ed 1998;78(3):F227–F229 Wilson-Costello D, Rao PS, Morrison S, Hack M. Radiation exposure from diagnostic radiographs in extremely low birth weight infants. Pediatrics 1996;97(3):369–374 Donadieu J, Zeghnoun A, Roudier C, et al. Cumulative effective doses delivered by radiographs to preterm infants in a neonatal intensive care unit. Pediatrics 2006;117(3):882–888 Arad I, Simanovsky N, Braunstein R. Exposure of extremely low birth weight infants to diagnostic X-Rays: a longitudinal study. Acta Paediatr 2009;98(2):266–269 Vachharajani A, Vachharajani NA, Najaf T. Neonatal radiation exposure. Neo Rev 2013;14(4):e190–e197 Berrington de González A, Darby S. Risk of cancer from diagnostic X-rays: estimates for the UK and 14 other countries. Lancet 2004; 363(9406):345–351 Hall P, Adami HO, Trichopoulos D, et al. Effect of low doses of ionising radiation in infancy on cognitive function in adulthood: Swedish population based cohort study. BMJ 2004; 328(7430):19 Dougeni ED, Delis HB, Karatza AA, et al. Dose and image quality optimization in neonatal radiography. Br J Radiol 2007;80(958): 807–815 Hellwig BJ, Wilson B. Quality improvement related to radiation safety chest radiography in the NICU. Radiol Manage 2013;35(2): 18–23, quiz 24–25
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Vol. 32
No. 10/2015
17
18
19
20
21
22
Quality improvement in radiography in a neonatal intensive care unit. Can Assoc Radiol J 2008;59(4):197–202 Ballinger PW, Frank ED. Merrill’s Atlas of Radiographic Position and Radiologic Procedure. Vol 3. St. Louis, MO: Mosby; 2003 Meerstadt PWD, Gyll C. Manual of Neonatal emergency X-ray Interpretation. London (GB): WB Saunders; 1994:1–6 Simanovsky N, Ofek-Shlomai N, Rozovsky K, Ergaz-Shaltiel Z, Hiller N, Bar-Oz B. Umbilical venous catheter position: evaluation by ultrasound. Eur Radiol 2011;21(9):1882–1886 Katheria AC, Fleming SE, Kim JH. A randomized controlled trial of ultrasound-guided peripherally inserted central catheters compared with standard radiograph in neonates. J Perinatol 2013; 33(10):791–794 Dennington D, Vali P, Finer NN, Kim JH. Ultrasound confirmation of endotracheal tube position in neonates. Neonatology 2012; 102(3):185–189 Bussières AE, Sales AE, Ramsay T, Hilles SM, Grimshaw JM. Impact of imaging guidelines on Xray use among American provider network chiropractors: interrupted time series analysis. Spine J 2014;14(8):1501–1509 Cobo ME, Vicente A, Corres J, Royuela A, Zamora J. Implementing a guideline for the request of chest and abdominal x-rays in nontrauma pathologic conditions in an ED. Am J Emerg Med 2009; 27(1):76–83 McWhirter E, Yogendran G, Wright F, Pharm GD, Clemons M; Cancer Care Ontario Practice Guidelines Initiative. Baseline radiological staging in primary breast cancer: impact of educational interventions on adherence to published guidelines. J Eval Clin Pract 2007;13(4):647–650 John SD, Moore QT, Herrmann T, et al. The Image Gently pediatric digital radiography safety checklist: tools for improving pediatric radiography. J Am Coll Radiol 2013;10(10):781–788 Thomas SM, Burch W, Kuehnle SE, Flood RG, Scalzo AJ, Gerard JM. Simulation training for pediatric residents on central venous catheter placement: a pilot study. Pediatr Crit Care Med 2013; 14(9):e416–e423 United Nations Scientific Committee on the Effects of Atomic RadiationSources and effects of ionizing radiation. Available at: http://www.unscear.org/docs/reports/2008/11-80076_Report_ 2008_Annex_D.pdf. Accessed September 12, 2012 Don S, Macdougall R, Strauss K, et al. Image gently campaign back to basics initiative: ten steps to help manage radiation dose in pediatric digital radiography. Am J Roentgenol 2013;200(5): W431–6
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