Quinn BP, Cevallos P, Armstrong A, Balzer D, El-Said H, Foerster S, Glatz AC, Goodman A, Goldstein B, Hainstock M, Janssen D, Kreutzer J, Latson L, Leahy R, Petit C, Shahanavaz S, Trucco S, Whiteside W, Zampi JD, Bergersen L.
Circ Cardiovasc Interv. 2020 May;13(5):e008172. doi: 10.1161/CIRCINTERVENTIONS.119.008172. Epub 2020 May 15.
Take Home Points:
- Individual centers can likely achieve radiation reduction via many of the techniques described in this work.
- Multi-center collaboratives (i.e. PAC3, PC4, etc) are increasingly being recognized as a powerful tool in leading quality improvement efforts by facilitating shared learning between sites and maintaining center engagement.
Commentary from Dr. Konstantin Averin (Edmonton), catheterization section editor of Pediatric Cardiology Journal Watch: Infants and children are at particular risk of developing long-term complications (i.e. cancer) from exposure to ionizing radiation. The ALARA (“As Low As Reasonably Achievable”) principle was first introduced in the 1970s in the nuclear energy sector and was subsequently adopted in the medical field to caution providers to minimize radiation exposure. In the decades since some progress at reducing radiation exposure within congenital interventional cardiology procedures has been made but systematic, multi-center efforts are limited. The authors of this work report on a multi-center effort using rigorous quality improvement (QI) methodology to reduce radiation exposure among participating sites.
Details of the QI methodology, including the key driver diagram can be found in the manuscript. The main key driver domains (see below) were Processes for Improvement; Education for Staff and Physicians; Optimizing Operator Techniques; Optimizing Use of Equipment; and Equipment Manufacturer Discussion.
The primary outcome measure was Dose Area Product indexed to body weight (DAP/kg) with a goal to reduce radiation exposure by 10%. Procedures were broadly categorized into 3 groups based on expected radiation exposure – Radiation Exposure Categories (REC): 1 – low; 2 – medium; 3 – high. A total of 15,257 cases unique cases were entered by 8 sites between January 1, 2015 and December 31, 2017. Overall, there was a 19% decrease in DAP/kg with no change in fluoroscopy time. Most cases were REC 1 (70%) with the greatest decrease in DAP/in this category of cases. There was significant variability in baseline radiation exposures between sites but there were statistically significant reductions in radiation doses in all REC categories at all sites.
The most important drivers of radiation reduction seem to be the sharing of practices and operator techniques through regular webinars, online reporting tools allowing for tracking of progress, identifying center-specific areas for improvement and creation of institution radiation safety committees. Multi-center collaboratives (i.e. PAC3, PC4, etc) are increasingly being recognized as a powerful tool in leading quality improvement efforts by facilitating shared learning between sites and maintaining center engagement.