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Correspondence |
The Ionising Radiations (Medical Exposure) Regulations (IRMER) require duty holders to take part in a clinical audit programme and place responsibility on all staff involved in a medical exposure, including those acting as practitioner, to participate in a programme of audit to demonstrate compliance with established protocols and procedures.
Northumbria Trust has made a distinction between X-ray procedures that represent a distinct stage in the management of the patient and certain other procedures, such as endoscopic retrograde cholangiography, pain relief management, cardiology X-ray and orthopaedic X-ray procedures, for which the X-ray component of the investigation and/or treatment is closely and uniquely associated with the broader clinical undertaking. It has determined that for this latter group, responsibility for justifying the medical exposure could not readily be divorced from the wider aspects of patient management and that therefore practitioner responsibility should be vested in the relevant clinician, i.e. endoscopist, anaesthetist, cardiologist, orthopaedic surgeon, etc. We have implemented, on behalf of the employer, a training programme for these staff groups enabling them to be practitioners. The training was not intended to enable candidates to act as operators, as this task is generally performed by radiographers. It had been our intention to include both theoretical and practical aspects within the training and in particular we wished to incorporate an audit exercise. Successful completion of the audit was regarded as an essential prerequisite to accreditation by the employer as a practitioner.
The purpose of this letter is to detail elements of that training and to describe in general terms the results of audits carried out by the first group of participants. We believe that this is the first time that a radiological audit of this nature has been undertaken as part of a training exercise by non-radiology clinical staff and feel that they responded positively to the training experience. We therefore wish to share with other groups who may be involved in similar efforts, some general observations regarding this form of training.
The content of the course was based on the syllabus in Schedule II of IRMER but was designed with the hazards and pitfalls associated with the use of image intensifier equipment in mind. Training was carried out on six different occasions at three separate centres within the Trust. A total of 41 prospective practitioners attended. Most were clinicians of consultant status with considerable experience in specialties such as cardiology, orthopaedic surgery or general medicine. Some registrars also attended. All had previously been involved in clinically directing interventional X-ray procedures prior to the introduction of IRMER and had been identified as IRMER practitioners. A minority of participants were deemed to be performing as operators but it was not within the remit of the current training programme to address this training requirement.
Participants were provided with text-based reading material 2 weeks prior to the start of the course, representing a nominal 3 h of private study. Group training was concentrated into a single day consisting of lectures, discussion sessions, a formal assessment and a practical demonstration of dose and image quality assessment, representing a further total of 6 h training.
Candidates were asked to provide, within a period of 2 months following the lectures, an audit of practice involving the use of ionizing radiation. The audit was intended to be an exposition of individual practice, although an audit of collective practice limited to a given procedure within a particular speciality was also allowed. A defined aim of this audit was to provide material to support existing practice and to identify potential changes.
Although considerable flexibility was allowed regarding the format of the audit, a prospective sequential survey of one or more dose indicators was preferred. It was suggested that where more than one X-ray investigation was performed, a single X-ray procedure, e.g. hip pinning, dynamic hip screw, should be identified for the purposes of audit. Dose–area product was preferred as a dose indicator, but it was appreciated that this could not readily be determined for most mobile C-arm intensifiers. Screening time was also, therefore, acceptable. Some alternative audits were agreed where neither of these indicators was possible. In some cases the use of retrospective data was agreed where the use of prospective data would have introduced an unacceptable delay.
Owing to the individual nature of the exercise, likely variations in data collection technique were anticipated. It was not intended, therefore, that screening times or other patient dose data obtained as part of such an audit would provide a definitive demonstration of adherence to any diagnostic reference level.
A target of 11 consecutive patients was suggested. This number was taken as a minimum sample size that also enabled straightforward computation of the median. Candidates were asked to comment upon patient doses overall and to review recorded outcomes where appropriate. Potential sources of variability in the selected dose indicator, e.g. extremes of patient weight or height, technically difficult interventions, level of staff training and experience, etc., were to be identified where possible. Provisional recommendations were encouraged.
Audits were to be reviewed jointly by the Clinical Director of Radiology and the Radiation Protection Adviser against established audit standards. Individual results were to be regarded as confidential. A successful audit was required prior to confirmation of practitioner status by the employer.
15 audits were received within the period up to 4 months following the end of the final lecture day. One has been returned for an additional analysis. The remainder were approved. A number of candidates carried out an audit of clinical evaluation and outcomes relating to their specific areas of interest. Most, however, audited patient dose indicators such as dose–area product, screening time and technique factors as a guide to the range and overall levels of risk associated with those procedures they would be most likely to authorise.
Benefits accrued by the complete training programme were assessed through a questionnaire distributed to the candidates prior to the completion of the audit but directly after delivery of the formal lecture programme, which included details of the proposed audit. Candidates were not critical of the style or content of the proposed audit. It is likely that the requirement to produce an audit report several weeks following the completion of the formal lecture programme acted as a significant reinforcing influence.
All participants expressed a clear commitment to the broader principles of patient dose optimization in fluoroscopy. One participant demonstrated reduced screening times following the IRMER course, which could be attributed to no influence other than an increased awareness of radiation protection issues. A further candidate identified a lack of recorded outcomes for some patients. In one instance it was concluded that a very infrequent procedure performed by the individual concerned could no longer be justified from a radiation protection point of view. A number of audits were able to relate higher screening times to technical difficulties with the intervention. Where both dose–area product and screening time had been recorded, it was noted that correlation was generally weak.
In general it was not possible to compare median dose indicators (or screening times) with local or national diagnostic reference levels as no such reference levels were available. Since examination types were very specific, it was only possible to make broader comparisons in a few instances. However, some candidates attempted to put screening times into perspective by detailing specific tasks to be performed, e.g. "wait for the biliary tree to fill with contrast...".
We believe that the requirement to undertake an audit of practice has contributed positively to the learning experience. Participation in an ongoing audit programme is not only a requirement of IRMER but is also a prerequisite of broader professional practice. We suggest, therefore, that this approach may be useful elsewhere.
Yours etc.,
1 Regional Medical Physics Department, Newcastle General Hospital, Westgate Road, Newcastle-upon-Tyne NE4 6BE 2 X-Ray Department, North Tyneside General Hospital, North Shields NE29 8NH, UK
Received for publication July 2, 2002. Accepted for publication May 7, 2003.
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