ASSESSMENT OF PAEDIATRIC X-RAY EXAMINATION PRACTICES IN TWO TERTIARY HEALTH INSTITUTIONS (CASE STUDY OF ENUGU METROPOLIS)

TABLE OF CONTENTS

Title Page…………………………………………………………………………………………………….i

Dedication……………………………………………………………………………………………………ii

Approval Page……………………………………………………………………………………………..iii

Certification…………………………………………………………………………………………………iv

Acknowledgement………………………………………………………………………………………..v

Table of Contents…………………………………………………………………………………………vi

List of tables………………………………………………………………………………………………..vii

List of figures………………………………………………………………………………………………viii

Abstract……………………………………………………………………………………………………….ix

CHAPTER ONE: INTRODUCTION

1.1     Background of study…………………………………………………………………………….1

1.2     Statement of the problems…………………………………………………………………….4

1.3     Purpose of the study……………………………………………………………………………..4

1.4     Significance of the study……………………………………………………………………….5

1.5     Statement of hypotheses………………………………………………………………………..6

1.6     Scope of the study…………………………………………………………………………………6

1.7     Literature review…………………………………………………………………………………..7

CHAPTER TWO: THEORITICAL BACKGROUND

2.0     Paediatric radiography………………………………………………………………………….15

2.1     Child development and psychological considerations………………………………16

2.2     Environment………………………………………………………………………………………..17

2.3     Challenges…………………………………………………………………………………………..18

2.4     Paediatric radiation protection issues……………………………………………………..18

2.5     Equipments………………………………………………………………………………………….19

2.6     Justification of radiological exposures……………………………………………………20

2.7     Optimization for paediatric radiation protection………………………………………21

2.8     X-Radiation…………………………………………………………………………………………21

2.9     General recommendations for paediatric radiology………………………………….26

CHAPTER THREE: RESEARCH METHODOLOGY

• Research design…………………………………………………………………………………..30

3.2     Target population…………………………………………………………………………………30

3.3     Sources of data collection……………………………………………………………………..30

3.4     Method of data collection……………………………………………………………………..30

3.5     Method of data analysis………………………………………………………………………..35

CHAPTER FOUR: DATA ANALYSIS AND PRESENTATION

4.1     Frequency distributions of common paediatric x-ray examinations…………..36

4.2     Radiographic techniques and image quality…………………………………………….42

4.3     Image quality audit……………………………………………………………………………….48

4.4     Causes of film reject…………………………………………………………………………….49

CHAPTER FIVE: DISCUSSION, CONCLUSION AND RECOMMENDATIONS

5.1     Discussion…………………………………………………………………………………………..50

5.2     Summary of findings…………………………………………………………………………….56

5.3     Recommendations………………………………………………………………………………..58

5.4     Limitations of the Study……………………………………………………………………….58

5.5     Areas of Further Research…………………………………………………………………….58

References

Appendix

LIST OF TABLES

Table 1:Radiological examination/projections included in the study

Table 2: Image criteria for anteroposterior/posteroanterior chest examinations from the, “European guidelines on quality criteria for diagnostic radiographic images”.

Table3:A graded scoring system developed to highlight the differences between the two departments.

Table 4a:Monthly distributions of common paediatric x-ray examinations at UNTH

Table 4b: Monthly distribution of common paediatric x-ray examinations at NOHE

Table 5a:Age/gender distribution for common paediatric x-ray examinations at UNTH.

Table 5b: Age/gender distribution for common paediatric x-ray examinations at NOHE.

Table 6:Percentage of films displaying poor radiographic techniques with regard to radiation protection and image quality

Table 7:Percentage of films displaying excellent radiographic techniques with regard to radiation protection and clinical information displayed.

Table 8: Comparison between examination type and poor radiographic techniques

Table 9:Comparison between examination type/projection and image quality

Table 10: Comparison of radiographic techniques and image qualitybetween UNTH and NOHE

Table 11:Image quality audit practice at UNTH and NOHE

Table 12:Frequencies of common causes of film reject in paediatric examination practices in UNTH.

LIST OF FIGURES

Figure I:Frequency chart for Paediatric x-ray examination UNTH

Figure II:Frequency chart for routine paediatric x-ray examinations in NOHE.   

Figure III:Percentage of films which satisfies the European Image Criteria.

ABSTRACT

Justification and optimization are the key principles in the protection of patients exposed to ionization radiation from diagnostic purposes. This is more important in the imaging of children because they are more susceptible to the effect of ionizing radiation and they have longer life expectancy compared to adults. As a result of this, there is also recent requirement for diagnostic radiology department to demonstrate compliance with these principles. A study was carried out to assess and compare the paediatric x-ray examination practices in two tertiary institutions in Enugu metropolis, UNTH and NOHE, with the aim of determining the frequency of paediatric x-ray examinations, quality of radiographic techniques and image quality, practice of image quality criteria and feedback to staff, and causes of film reject, The departmental registers were used to determine the frequency of common paediatric x-ray examinations. Retrospectively, 40 radiographs were collected from the medical records of the two radiologicaldepartments studied, to determine the quality of radiographic techniques and image quality, while 34 rejected radiographs were collected over a period of 3 weeks at UNTH to determine the causes of film rejects in this department. Some radiographers were interviewed to ascertain the practice of image quality audit. All the radiographs collected were assessed by a radiographer from each department. The data was analyzed and the result showed that the paediatric x-ray examination request patterns are not the same in the two departments studied. While UNTH has high number of chest request which accounts 62.1%, with higher percentage of males (57.7%) under the age groups of 0-5 years, NOHE has extremities as the most common requested x-ray examination which accounts 71.2%, with higher percentage of females (50.5%) but higher percentage of males are under the age group of 0-5 years (41.4%). In both departments, more than half of films of the film assessed satisfied most of the European image criteria; 69.3% at UNTH displayed excellent radiographic techniques, and 65.7% at NOHE. The image quality audit and feedback to staff is not fully practiced. Also, the common cause of film reject at UNTH is “underexposure” which accounts 52.94% of the rejected radiographs. The result of the hypotheses stated showed that examination type/projection requested affects poor radiographic techniques and image quality in each department and there is a significant difference in some radiographic techniques between UNTH and NOHE. With all these findings, there is need for self-audit and re-evaluation of procedures where necessary in both departments studied.

CHAPTER ONE

INTRODUCTION

• BACKGROUND OF STUDY

Paediatric radiography is a subspecialty of radiology involving the imaging of fetuses, children, adolescents and young adults. In radiography, paediatricsconstitutes patients within the age range of 0-15years. For diagnostic purposes they can be divided into six main groups as follow: (a) Birth-6months, (b) Infancy (6months-3years), (c) Early childhood (3-6years), (d) Middle childhood (6-12years), and adolescent (12-15years).⁽¹⁾  Each of these groups has a peculiar need towards obtaining diagnostic quality images at the least attainable risks. Paediatric radiography involves the use of X-rays in the diagnostic examination of a child for clinical conditions related to the different parts of the body.It has been identified as one of the most common diagnostic procedures in paediatrics, both the sick and the healthy ⁽²⁾.

To successfully diagnose a paediatric condition, high quality images are needed. Children can be uncooperative and obstructive when undergoing radiography and often challenge the very technique and ability of the imaging staff within whose custody they have been temporarily placed. Therefore,paediatric radiography comes with many challenges.

Medicine has used ionizing radiation for decades to help diagnose or treat children (and adults).  There isno doubt that imaging has saved lives.  Medical imaging use has also grown exponentially in the past few years, ⁽³⁾ particularly in paediatric radiography.  Thus, thereis frequent demand of x- ray examinations for diagnosis of a number of paediatric pathologies.

The United Nations Scientific Committee on the Effects of Atomic Radiation (UNSCEAR, 2008), estimated that worldwide, there were 3.6 billion imaging studies per  year (survey covering period of 1997- 2007) using ionizing radiation comparing the previous report of 2.4billion per year (survey covering period of 1991 – 1996) – an increase of approximately 50%⁽³⁾. It was also reported by Arroe that the frequency of examinations changes, depending on the neonatal birth weight (BW), age and disease of the child ⁽⁴⁾. In addition, there is substantial evidence to suggest that children are more susceptible to the effects of ionizing radiation than adults ⁽⁵⁾, which places an added burden on radiographers to attain the best possible result every time.

The United Nations Scientific Committee on the effects of Atomic radiation (UNSCEAR)⁽³⁾ also, emphasized that risks from exposure to ionizing radiation are dependent on the age at which exposure occurs and that exposure during childhood results in a likely two to three (2-3) fold increase in life time risk for certain detrimental effects (including solid cancers) compared with that in adults: children, therefore need more careful evaluation with regard to the frequency of examinations and radiographic technique needs to be even more exacting. European Commission has recognized the need for special treatment of children in the x-ray department, in both the “European guideline on quality criteria for diagnostic radiographic images in paediatrics” ⁽⁵⁾and more recently in the Council Directive 97/43/Euratom ⁽⁶⁾ on the protection of individuals against the dangers of ionizing radiation. The guidelines suggest examples of good radiographic techniques and present useful image quality criteria for a number of common paediatric examinations, with the aim of producing high quality images at lowest possible dose to the patient. The Council Directive 97/43/Eurotom ⁽⁶⁾ recommends that special consideration be given to diagnostic radiographic procedures involving children.

Until now, researches on common routine radiological investigations ofpediatrics were mainly on radiation protection, radiation dose to paediatric patients, estimation of radiation induced cancers to patients, justification and optimization of radiological requests, and others related to the after effects of common routinepaediatric x- ray examinations ^(8-17)_,  but no research to the best of the researcher’s knowledge has been carried out on the assessment of paediatric radiographic practices and request patterns in Nigeria. Therefore the aim of this study is to assess and compare paediatric x–ray examination practices and request pattern in two tertiary health institutions in Enugu metropolis.

1.2     STATEMENT OF PROBLEMS

1. X-ray imaging is being increasingly used for diagnosis of paediatricpathologies². Unfortunately, there is substantial evidence to suggest that children are more susceptible to the effects of ionizing radiation than adults⁽³⁾. Evaluation of the frequency distribution of paediatric examinations therefore becomes very essential.
2. In addition, there is no documented evidence of audit of paediatric radiography practice in our environment to ensure safe and standard practice.
3. The researcher in the course of clinical postings observed that common routine paediatric x-ray examination practices in theradiology departments being studied were not properly documented.

1.3     PURPOSE OF STUDY

The purpose of the study is to assess paediatric X-ray examination practices and request patternin University of Nigeria Teaching Hospital, Ituku-Ozalla (UNTH) and National Orthopedics Hospital Enugu (NOHE), in Enugu metropolis.

The specific objectives are as follows:

1. To determine the frequency of common routine paediatric x-ray examinations and monthly distribution of the frequency of the investigations in the localities studied.
2. To assess the radiographic techniques used, and radiation protection adopted based on radiographic films.
3. To assess the practice of image quality audit and feedback to staff.
4. To assess the causes of rejects in paediatric radiography in these health institutions.
   • SIGNIFICANCE OF STUDY

Findings of this study will portray the quality of the paediatric examination practices in each health institution studied and also provide documented information on the following:

1. The frequency of common routine paediatric x-ray examinationsand their monthly variations, as well as the corresponding projections, in the two tertiary health institutions.
2. Practice of image quality audit and feedback to staff.
3. The causes of film reject in paediatric radiography in these health institutions.
4. The quality of the radiographic techniques used in these departments, as well as the image quality.

• STATEMENT OF HYPOTHESIS

1. There is no significant difference between examination type/projections and poor radiographic techniques.
2. There is no significant difference between examination type/projections and image quality.
3. There is no significant difference in radiographic techniques and image quality between UNTH and NOHE.
   • SCOPE OF STUDY

This research will be carried out in two tertiary health institutions in Enugu metropolis. They include University of Nigeria, Teaching Hospital, Ituku–Ozalla (UNTH) and National Orthopedics Hospital, Enugu (NOHE). The department register and patient request cards will be assessed, for a period of one year, between the months of January 2011 to December, 2011, to determine the frequencies of common routine examinations. This study will cover paediatricpatients within the age range of 0-15years.

1.7     LITERATURE REVIEW

        Medicine has used ionizing radiation for decades to help diagnose or treat children (and adults). There is no doubt that this imaging has saved lives. Medical imaging use has grown exponentially in the past few years⁽⁷⁾.

Kyriou, et al⁽⁸⁾ carried out a research on the key factors in the optimization of paediatric x-ray practices with the aim of assessing and comparing all aspects of the paediatric radiographic procedures at two specialist (C₁ and C₂ ) and non-specialist (G₁  and G₂ ) centers. 16 common routine x-ray examinations of paediatrics were investigated. The result showed a higher frequency of skull examinations at G_{1 and} G₂ compared to those at the specialistcenters. The frequency of abdominal radiographs performed at C₂ was higher. There was also an increased frequency of pelvic radiographs at C₁ and C_{2 .}There was low value of chest radiographs in G₁. C₁ and C₂ also had comprehensive and precise referral review for many less common procedures in addition to these for the 16 common examinations under review but C₂ did not have a radiologist constantly on site. Consequently, the frequency of abdominal and chest radiographs was higher at C₂ than C₁. Neither G₁ nor G₂ had their own paediatric referral criteria but followed the guidelines published by the Royal College of Radiologists (RCR). However, the RCR guidelines were not always strictly adhered to and there were no specific referralcriteria in place for less routine examinations. This was reflected in the increased frequency of certain examinations (e.g. skull radiographs) at G₁ and G₂.

Hart, et al ⁽⁹⁾ in their study, ‘frequency and collective dose for medical and dental x-ray examinations in UK, with the aim of determining the frequency and collective dose for medical and dental examinations in UK, estimated the x-ray examinations to be 46million in 2008, a 10% rise on the number for financial year 1997/98 with estimated dose of 24,700manSv in the year 1991. The increase is mainly due to the greater prevalence of computed tomography (CT) examinations which account for 68% of collective dose from all medical and dental examinations. Conventional radiographic and dental examinations contribute only 19% of collective dose. In conclusion, there is increase in the annual UK per caput dose from0.33 to 0.4mSv. Despite the increase, the value is low compared to other countries due to both a lower frequency of the examinations per head of the population and generally lower dose per examination in UK.

Kettunen, et al ⁽¹⁰⁾ in another study “Radiation dose and Radiation Risk to the fetuses and newborns”, found out that among the 43 newborns that underwent x-ray examinations in their early years, chest and abdominal x-rays were the most common studies. Only a few studies of the skull, bone age and hip joints were performed.

Bushra, et al ⁽¹¹⁾ carried out a study on radiation measurement and risk estimation for paediatric patients during Routine Diagnostic examinations. Their aim was to evaluate the entrance surface dose (ESD) to the patient during some common routine paediatric x-ray examinations, such as chest PA/AP, Abdomen, pelvis and skull), and to estimate the radiation induced cancer to paediatric patients, per procedure. The result showed that AP projection for chest exam for neonates’ patients 0-1year old, in just one of the hospitals was 47% higher than UK references level. ESD to the patients during pelvis examination was higher than other examinations. The risk of radiation induced, cancer of (skin, ovaries, urinary bladder, ovaries uterus) effective dose equivalent was 0.13 x 10^-6. In conclusion values of ESDs and scattered thyroid dose generally increased with decrease in patient’s weight and ages, selected techniques factors as well as the radiographic equipment used. This study showed that there is a statistically significant correlation between patient dose and weight.

Puch-kapst, et al ⁽¹²⁾ carried out a study on radiation exposure in 212 very low and extremely low Birth weight infants with the aim of the study was determining the frequency and estimating effective radiation dose (E) from conventional diagnostic radiographs for infants who had birth weight of less than equal to 1500g. Entrance skin doses were experimentally measured for all standard weight dependent exposure setting. In the results of 212 very low Birth weight infants, 194 required at least one conventional radiograph. A total of 1,555 radiographic procedures were needed for various medical conditions. More than two-thirds (2/3) of the 1503 conventional radiographs were chest radiographs (67%). The frequency of radiographic procedures depended on various conditions, including birth weight.

Hiorns, etal, ⁽¹³⁾ carried out a study on review of current local dose area product levels for paediatric with the aim of assessing dose area product (DAP) values in children having fluoroscopy examination and revising the local diagnostic levels (DRLs). 2,658 examinations performed in a dedicated fluoroscopy room over a period of months were analyzed. The eight most commonly performed examinations were assessed. The results showed lower DAP values than the national reference dose (NRDs). In conclusion, the small DAP values in all examinations demonstrated the substantial reduction in dose and consequent risk that can be achieved when both equipment performance and operator technique are optimized.

Ono, et al ⁽¹⁴⁾, carried out a study on neonatal doses from x-ray examinations by birth weight in a neonatal intensive care unit. The aim of this study was to investigate the frequency and type of x-ray examinations performed on neonates classified according to their birth weight in a neonatal intensive care unit (NICU). In this study, the radiology records of 2,408 neonates who were admitted to the NICU of Oita Prefectural Hospital were investigated. This study revealed that the neonates with earlier gestational ages and lower birth weights required longer NICU stays and more frequent x-ray examinations made using a mobile x-ray unit. The average number of x-ray examinations performed on neonates of less than 750 g birth weight was 26 films per neonate. In regard to computed tomography and fluoroscopy, no significant relationship was found between the birth weight and number of x-rays. This study revealed that the entrance-surface dose per neonate was dependent upon the birth weight, while the maximum dose was not dependent upon the birth weight. The average neonatal dose in the NICU was predominantly from computed tomography and fluoroscopy.

Pedrosa et al⁽¹⁵⁾, researched on the frequency of x-ray examination of neonateswith the aim to evaluate the entrance surface dose (ESD), the body organ dose (BOD) and the effective dose (E) resulting from pediatric radiological procedures with the use of portable X-ray equipments, as well as the examination frequencies. The children were classified according to their weight and age groups, and the study included three sectors of the intensive care unit of a large reference pediatric hospital in Rio de Janeiro. The result showed a total of 518 radiographs have been performed, (424 for chest and 94 for abdomen). The statistical data were compared with previously published results. In conclusion, the mean value of ESD and E varied widely among neonates. The highest number of radiographs per infant peaked 33 for chest examination in the age group 0-1 year.

Cornelia, et al ⁽⁶⁷⁾, carried out a research on the diagnosticpaediatric radiology and the resulted collective effective dose with the purpose of updating the annual frequency of x-ray examinations and the pattern of paediatric radiology and also assessing, in terms of effective dose, the magnitude of pediatric patient exposure during conventional x-ray examinations, selected by their high frequencies or their relatively high doses delivered to patient. Pattern of paediatric radiology showed a mean increase of CT frequency of 3.1% of total annual X-ray procedures

Sulieman, et al ⁽¹⁷⁾, carried out a research on the radiation doses to paediatric patients and comforters undergoing g chest x-rays. This study aims to determine the entrance surface dose (ESD), organ, effective doses and propose a local diagnostic reference level. Patients were divided into three groups: organ and effective doses were estimated using National Radiological Protection Board software. The ESD was determined by thermoluminescentdosimeters for 132 children and 76 comforters. The average ESD value was 55±8 µGy. The effective dose for patients was 11.2±5 µSv. The mean radiation dose for comforter is 22±3 µGy. The radiation dose to the patients is well within dose constraint, in the light of the current practice.

In another study ⁽¹⁸⁾ carried out in Africa, Asia and Eastern European countries, ‘Paediatric CT examinations in 19 developing countries: frequency and radiation dose’. The aims of this study were to investigate the frequency of computed tomography (CT) examinations for paediatric patients below 15 years of age in 128 CT facilities in 28 developing countries of Africa, Asia and Eastern Europe and to assess the magnitude of CT doses. Radiation dose data were available from 101 CT facilities in 19 countries. The dose assessment was performed for chest, chest (high resolution), lumbar spine, abdomen and pelvis CT examinations using standard methods. The results show that on average the frequency of paediatric CT examinations was 20, 16 and 5 % of all CT examinations in participating centers in Africa, Asia and Eastern Europe, respectively. Eleven CT facilities in six countries were found to use adult CT exposure parameters for paediatric patients, thus indicating limited awareness and the need for optimization. CT images were of adequate quality for diagnosis. The study has indicated a stronger need in many developing countries to justify CT examinations in children and their optimization.

Eze, et al, ⁽¹⁹⁾   carried out a research on audit of rejected repeated x-ray films as a quality assurance element in a radiology department with the aim of determining the causes, number, percentage and sizes of rejected radiographic films with the view of adopting measures that will reduce the rate and number of rejected films. This was carried out over a two year period with the data collected retrospectively. A total of 15,095 films were used in the study period and 1,338 films (8.86%) were rejected. The greatest cause of film reject was radiographers’ faults 547 (40.88%) followed by equipments’ faults 255 (19. 06%) and the highest reject rate was for the films used for examination of the spine. In conclusion, reject films are not billable and patients receive additional radiation.

In the literatures reviewed, their researches were mainly on radiation protection, calculation of radiation dose and estimation of effective dose to paediatric patients, estimation of radiation induced cancers to patients, justification and optimization of radiological requests and others related to the after effects of common routine paediatric x- ray examinations, and the effect of neonatal birth weight and age on the frequency of x-ray examinations of paediatrics, ^(8-16)_, but no research to the best of the researcher’s knowledge has been carried out on the assessment of paediatric radiographic practices and request patterns in Nigeria.

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