CAUSES OF REPEATS IN PAEDIATRIC RADIOGRAPHY (CASE STUDY OF THREE TERTIARY HOSPITALS IN ENUGU METROPOLIS)

ABSTRACT

Paediatric radiography comes with many challenges, unlike in adult’s radiography; children cannot always understand and comprehend a change of environment and cannot obey radiographer’s instruction which may result in repeat cases. Children are more radiosensitive than adults and have a longer life expectancy over which they may develop cancer from exposures to ionizing radiation due to high level of repeats. This is a cross sectional study aimed at determining: the factors that lead to repeat cases in paediatric radiography, the rates of repeats during paediatric radiography and to compare the causes of repeats in paediatric radiography in the hospitals studied. The target population for this study comprises paediatric radiography patients that came for radiography examination during the period of research in the study centres. The three tertiary hospital studied are University of Nigeria Teaching Hospital (UNTH), National Orthopaedic Hospital Enugu (NOHE), and Enugu State Teaching University hospital (ESUTH). Also practicing radiographers working in the three tertiary hospitals in Enugu metropolis where the research was carried out formed part of the study population and were used to elicit information about the factors that lead to paediatric repeat cases. A convenience sampling technique was used in this study. Questionnaire, observation and spy sheet were used as source of data collection. Result of this study showed that repeats in paediatric radiography occur due to patient’s movement, lack of specialised paediatric accessories, lack of dedicated unit, radiographer’s error, equipment error and processing error. The respondents in UNTH (18.5%) associated paediatric repeats mainly to patient’s movement and lack of dedicated paediatric immobilization devices. Most respondents in NOHE (66.7%) blamed paediatric repeats to lack of paediatric immobilization devices leading to patient movement and lack of dedicated unit, while most respondents (50%) in ESUTH blamed paediatric repeats on patient’s movement and lack of dedicated paediatric immobilization accessories. The study showed that majority of the respondents (70%) said that repeat rates occur intermittently. The overall repeat rates recorded is 43.8% (n=64).  The repeat rates in each hospital studied are, UNTH 45.3% (n=29), NOHE 29.7% (n=19), and ESUTH 25% (n=16). Examinations where the repeat rates occurred are; chest [39% n=25], extremities [26.6% n=17], skull is [20.3% n=13] and abdomen [14.1% n=9].Results suggest that hospitals should provide specialised paediatric accessories, and establish a paediatric dedicated unit to reduce paediatric repeats minimally because paediatric repeats can lead to increase in radiation dose, predisposing the paediatric to cancer and other effects of ionizing radiation in future.

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 problem..………………………………………………5

1.3     Purpose of study……………….……………………………….……5

1.3.1 Specific objective of study…..………………………….………………6

1.4 Significance of study…………………………………………………..6

1.5 Scope of study………….…….…………………………………………6

1.6 Operational definition of terms…………………………….……………..6

CHAPTERTWO: LITERATURE REVIEW

2.1 Evaluation of repeat rates in radiography…………………………….8

2.2 Causes of repeats in radiography…………………………………….18

2.3 Theoretical Background of Study……….…………………………….22

2.3.1 Paediatric radiography……………..…………..……..……………22

2.3.2 Environment………………………………………………………….23

2.3.3 Equipment…………………………………………….………………..25

CHAPTER THREE: RESEARCH METHODOLOGY

3.1 Research Design………………………………………….….…….…27

3.2 Target Population……………………………………………………..27

3.3 Sample size and sampling technique………………………..………28

3.4 Sources for data collection…………………………………………….28

3.5 Instrument for data collection………………………….……………..28

3.6 Methods of data analysis……………………………………….……29

CHAPTER FOUR: RESULTS

4.1 Data presentation…………………………………………….………30

CHAPTER FIVE: DISCUSSION AND IMPLICATIONS OF RESULTS, CONCLUSION AND RECOMMENDATIONS

5.1 Discussion and Implications of Results…………….………….……46

5. 1.1 Background characteristics of the respondents……….…….……46

5.1.2 Objective 1 (Factors that lead to repeat cases in

paediatric radiography)…………………………………………….47

5.1.3 Objective 2 (Evaluation of the rates of repeats during

Paediatric radiography)…………………………………………………48

5.1.4 Objective 3 (Comparison of the causes of repeats in

paediatric radiography in the hospital studied)………………………..49

5.2 Conclusion……………………………………………………..…..49

5.3 Recommendations………………………………………………….49

5.4 Limitations of the Study…………………………………………..50

5.5 Areas of further research………………………………………….50

References

Appendix 1

Appendix 11

LIST OF TABLES

Table 1:Physical characteristic of Radiographers studied……………..…30

Table 2: Comparison between Hospitals of employment and factors

that Causes Repeats in Paediatric Radiography…..…………………..……38

Table 3: Comparison between Hospital of Employment and

Occurrence of Repeats in Paediatric Radiography.………………………39

Table 4: Comparison between Hospital of Employment and Service of Equipment in the Departments…………..….……40

Table 5: Comparison between Hospital of Employment and Efforts

made in the Department to Establish Dedicated Paediatric Unit…………….41

Table 6: Number of paediatric patients studied……………………………..42

Table 7: Different paediatric examinations carried out in hospital studied….43

Table 8:  Repeats rates in each hospital studied………………………..……44

Table 9: Distribution of repeat rates according to procedures………………..44

LIST OF FIGURES

Figure 1: Shows the cases of repeats in paediatric radiography………………31

Figure 2: Shows the occurrence of repeats in paediatric radiography………..32

Figure 3: Shows factors causing repeats in paediatric radiography………….33

Figure 4: Shows the rate at which equipment is serviced…………………..34

Figure 5: Shows availability of specialized accessories for paediatric

Radiography………………………………………………………35

Figure 6: Shows efforts made in the department to establish

a dedicated paediatric unit………………………………………..36

Figure 7: Long term effects of repeats in paediatric radiography…………..37

CHAPTER ONE

INTRODUCTION

• Background of study

Paediatric radiography is a branch of radiography that deals with the imaging of children. Paediatric radiography as an integral part of paediatric health care is frequently requested to assist in the diagnosis, management, and treatment of childhood disease and illness, Accurate interpretation of paediatric radiographs can depend entirely on the quality of images produced by the radiographer, yet there are few books available on this crucial aspect of radiographic practice.¹

Paediatric radiography explores radiographic practice within the content of the modern health service and focus on how our knowledge or understanding of paediatric growth, development and illness can inform and influence radiographic procedures. It includes detailed coverage of specific paediatric techniques and good practice-models, including the role of multi-modality imaging and looks specifically at radiation protection, the chest in the upper airway, the abdomen, neonatal radiography, trauma, orthopaedics and non-accidental injury. Children can be uncooperative and obstructive when undergoing radiography examinations and often challenge the very technique and ability of the imaging staff within whose custody they have been temporarily placed. In addition, there is substantial evidence to suggest that children are more susceptible to the effects of ionizing radiation than adults, which places added burden on both radiographer and radiologist to attain the best possible results every time. The United Nations Scientific Committee on the effects of Atomic Radiation (UNSCEAR) has 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- fold increase in lifetime risk for certain detrimental effects (including solid cancers) compared with in an adult.²  Children  therefore, need more careful evaluation with regard to the necessity of examination, and radiographic technique needs to be even more exacting  to avoid repeats. The European Commission has recognised the need for special treatment of children in the X-ray department. The guidelines suggest examples of good radiographic technique and present useful image quality criteria for a number of common paediatric projections, with the aim of producing high quality images at the lowest possible dose to the patient. To successfully diagnose a paediatric condition, high quality images are needed to give a diagnosis. To achieve this requires creating environment where a child is comfortable. This is one of the most essential elements to paediatric radiography. For imaging departments which specialise in paediatric radiography, this is very easy as rooms can be tailored to suit a child’s needs to avoid repeats. For example; bright wall designs, visual stimulation and toys. These can be permanent fixtures as the department would not need to cater to any other age range. For departments which only see children occasionally, creating a ‘child friendly’ environment is more difficult. It is usually achieved by creating one room a ‘child friendly room’ where murals/ stencils can be painted on the wall. Modern children’s hospitals are now designed with lots of glass to allow as much as natural light in as possible, the Evelina Children Hospital being one of these.³

Children do not all reach a sense of understanding at the same predictable age. This ability varies from child to child, and the paediatric radiographer must not assume that children will comprehend what is occurring. Generally, however, by the age of 2 or 3 years, most children can be talked through a diagnostic radiographic study without immobilization or parental aid. Most important is a sense of trust, which begins at the first meeting between the patient and the radiographer; the first impression that the child has of the radiographer is everlasting and forges the bond of a successful relationship. Successful radiographic studies to avoid repeats are dependent on two things; the radiographer’s attitude and approach to a child and the Radiographers preparation in the room. At the first meeting, most children are accompanied by at least one parent or caregiver. The following steps are important; Introduce yourself as the radiographer, who will be working with this child, find out what information the attending physician has given to the parent and patient. Explain what you are going to do and what your needs will be.Tears, fears, and combative resistance are common reactions for a young child.The radiographer must take the time to communicate to the parent and the child, in language they can understand, exactly what he or she is going to do. The radiographer must try to build an atmosphere of trust in the waiting room before the patient is taken into the diagnostic room. This includes discussing the necessity of immobilization as a last resort if the child’s cooperation is unattainable. Parent is in room as an observer, lending support and comfort by his or her presence and parent serves as a participator, assisting with immobilization.⁴

Sometimes children who act fearful and combative in the waiting room with the parent present will be more cooperative without their presence. This is the time when the radiographer’s communication skills are tested. Paediatric patients in general can include infants through children up to ages 12 to 14.⁵

However, older children can be treated more like adults, except for special care in gonadal shielding and reduced exposure factors because of their smaller size. In general, paediatric radiography should always use as short exposure times and as high mA as possible to minimize image blurring that may result from patient motion. However, even with short exposure times, preventing motion during exposures is a constant challenge in paediatric radiography, and effective methods of immobilization are essential. Reduction of repeat exposures is critical, especially in young children, whose developing cells are particularly sensitive to the effects of radiation. Proper immobilization and high mA, short exposure time techniques will reduce the incidence of motion unsharpness. Accurate manual technique charts with patient body weights should be used. Radiographic grids should be used only when the body part examined is greater than 10 centimetres in thickness. Each radiography department should keep a list of specific routines for paediatric imaging exam, including specialised views and limited examination series, to ensure that appropriate projections are obtained and no unnecessary exposures are made.⁶

It is not uncommon to encounter paediatric patients undergo repeat X-ray examinations after their initial X-rays are rejected for poor image quality thereby subjecting them to excess radiation exposure and avoidable extra cost. This creates a situation which necessitates the need to explore causes of repeat of X-ray examinations in some tertiary hospitals.

• Statement of problem

1. Paediatric radiography comes with many challenges, unlike in adult’s radiography; children cannot always understand and comprehend a change of environment and cannot obey radiographer’s instruction which may result in repeat cases.
2. Children are more radiosensitive than adults.³  They also have a longer life expectancy over which they may develop cancer from exposures to ionizing radiation due to high level of repeats.

• Purpose of study

The aim of this study is to ascertain the causes of repeats in paediatric radiography in three tertiary hospitals in Enugu metropolis.

• Specific Objective of Study

1. To determine the factors that lead to repeat cases in paediatric radiography in the tertiary hospitals where the research was carried out.
2. To evaluate the rates of repeats during paediatric radiography in the study centres.
3. To compare the causes of repeats in paediatric radiography in the hospitals studied.

• Significance of the study

1. This study will draw attention of practising Radiographers on the need to reduce the number of repeats in paediatric radiography.
2. This study will help to educate the radiographerson the causes of repeats and ways to avoid them in paediatric radiography.

• Scope of study

This study was done in three tertiary hospitals in Enugu Metropolis which include; University of Nigeria Teaching Hospital (UNTH), National Orthopaedic Hospital Enugu (NOHE) and Enugu State University Teaching Hospital (ESUTH) Parklane Enugu.

• Operational Definition of Terms

1. Diagnostic radiography

Diagnosticradiography is the medical science of producing images of the human body; it is the use of ionizing radiation and non-ionizing radiation to create images for medical diagnosis. The predominant test is still X-ray which is the second most used medical test after laboratory^.6

2. Paediatric patient

Paediatricpatient is a patient less than 15years or a length-based weight (per Broselow Tape) of 36kg or less. Patients who are known to be less than 15 years of age but whose weight exceeds 36kg may still be considered paediatric patients given their chronological age.⁷

3. Paediatric Radiography

Paediatric radiography is a branch of radiography involving the imaging of infants and children with ionizing radiation, and other forms of imaging modalities.

4. Repeat

Repeat is a radiograph which is retaken to provide further diagnostic information because the previous one is not of adequate diagnostic value.

5. Radiographer

A radiographer uses X-rays, ultrasound and other forms of imaging technology to examine patients. They also contribute to the interpretation of medical images and diagnosis of some illness and injuries. They may contribute towards establishing treatment plans and can also be involved in interventional procedures, e.g., the removal of Kidney stones. They have a patient care role and work in a variety of hospital departments, including theatre, accident and emergency departments. The amount of time and type of contact they have with patient depends on the specialist area they work in.⁸

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