Safety And Qualityarchive.rsna.org/2015/SafetyandQuality.pdf · Effective communication is a critical component of diagnostic imaging, capable of reducing diagnostic errors and improving

Safety And Quality

QS100-ED-SUA1

What Not to Miss: Five Years' of Resident Discrepancies on Pediatric ED Exams

Station #1

QS102-ED-SUA2

Analysis and Improvement of Written Radiology Reports: A Single Center Experience

Station #2

QSE-SUA

Quality Storyboards Sunday Poster Discussions

Sunday, Nov. 29 12:30PM - 1:00PM Location: QS Community, Learning Center

AMA PRA Category 1 Credit ™: 1.00

Participants

Sub-Events

ParticipantsMichael Baad, MD, Chicago, IL (Presenter) Nothing to DiscloseDavid M. Kromrey, MD, Chicago, IL (Abstract Co-Author) Nothing to DiscloseSeng Ong, MD, Chicago, IL (Abstract Co-Author) Nothing to DiscloseMario F. Zaritzky, MD, Chicago, IL (Abstract Co-Author) Medical Advisor, Cook Group IncorporatedKate A. Feinstein, MD, Chicago, IL (Abstract Co-Author) Nothing to Disclose

PURPOSE

Overnight studies at our institution are interpreted by an on call radiology resident, with a final interpretation provided in themorning by the attending. Discrepancies between these two interpretations which result in significant alterations in patientmanagement are labeled "Significant Discordances." Through experience and discussions with the ED, there is a subjective increasein discordances as new call takers begin as well as typical mistakes that are commonly made. The objective of this qualityimprovement project is to reduce the discrepancies between these two interpretations through an initiative focused on a review oftypes of prior mistakes, identification of patterns of mistakes and organized education and periodic review of these findings.

METHODS

All interpretations of pediatric ED exams submitted though the STAT Consult preliminary interpretation system were retrieved over a5 year period from January 1, 2010 to December 31, 2014. Final interpretations flagged as a "significant discordance," that is, anerror which would result in a significant alteration in patient management, were selected yielding 336 unique accession numbers.Repeat examinations for the same error were eliminated for a total of 322 studies over the 5 year period. These studies were thenreviewed by two resident radiologists, coded for type and location of error. The time and date of the examination, the PGY level ofthe resident on call, and the attending submitting the final interpretation were also recorded. Errors were grouped as "CommonMistakes," "Bad Mistakes," and "Gotchas" with example cases in each category collected. Findings and example cases werepresented and discussed with the entire residency class.

RESULTS

Of the 322 studies, the most common discordances were missed fractures, missed pneumonia and overcall of fractures comprising46%, 18%, and 4% of total significant discordances respectively. Of missed fractures, 36% involved missed fractures of the feetand ankles and 61% missed fractures of the hands and wrists, with distal radial buckle fractures alone accounting for 20%. Themost common fracture missed however, were phalangeal fractures of the hand at 24%. Most discordance occurred during July,August and September and the least in December. PGY-3 residents had the most discordances, accounting for 59% of alldiscordances. Many errors were found to be subtle fractures involving the phalanges and pneumonias most evident on lateral views.

CONCLUSION

Missed fractures and pneumonias account for a majority of resident mistakes on call, often subtle and most evident on lateralviews. Regular review should be performed on these types of findings commonly found in pediatric exams. PGY-3 residents accountfor a majority of discordances, often at the beginning of call in the summer months, and therefore efforts at our institution havefocused on educating incoming call takers using the mistakes of the their colleagues. Additionally, efforts should be made to includelateral views when appropriate and improve histories in radiographs involving the hands and feet. This has directly resulted ininitiatives to obtain dedicated views of a single digit in cases of focal pain as well as a program whereby technicians will identify theprecise location of the patients' pain when available.

ParticipantsBenjamin D. Lack, MD, Royal Oak, MI (Presenter) Nothing to DiscloseJames Nugent, Rochester Hills, MI (Abstract Co-Author) Nothing to DiscloseKurt E. Tech, MD, Grosse Pointe, MI (Abstract Co-Author) Nothing to Disclose

PURPOSE

Effective communication is a critical component of diagnostic imaging, capable of reducing diagnostic errors and improving patientcare. Written radiology reports are among the most important means of communication between radiologists and clinicians and are acore component of every imaging study. A proper written report serves a number of functions with the ultimate goal ofcommunicating the results of an imaging study in an accurate and easily understood manner. The purpose of this study was toanalyze and improve the quality of radiology reports at our institution.

METHODS

A total of 997 radiology reports created at our institution during 2011 were randomly selected for study inclusion. Reports wereassessed for content, clarity, typographical errors, and format preference. Both internists and radiologists scored reports in eachcategory on a scale of 1-4 (1= best, 4= worst). Participants were also asked whether they preferred the impression at the

QS104-ED-SUA3

My First PQI Project- Using Storyboarding in QI Education

Station #3

QS106-ED-SUA4

Employment of Root Cause Analysis and Lean Techniques to Improve Communication of SurgicalRetained Foreign Objects

Station #4

beginning or end of the report, how often they read the findings section, and for suggestions regarding ways to improve reportquality. Univariate analysis and statistical comparison between scores for both physician groups were performed. A radiology reportimprovement plan was implemented based on data analysis and internists scored 305 subsequent reports from 2012 to evaluatereport improvement. Metrics to measure report quality:A panel of radiologists at our institution met with university professors fromthe Writing and Rhetoric Department and representatives of the Internal Medicine Department to discuss appropriate metrics tomeasure radiology report quality. Consensus was achieved regarding the importance of report content, clarity, and proof readingwhich are defined below. Content: Report is relevant to clinical situation and question.Clarity: Report has a clear style and presentsinformation in a simple logical order.Proof Reading: Report contains accurate grammar and spelling without dropped words. ReportImprovement Plan:A report improvement plan was developed to address the specific report quality metrics measured during theinitial evaluation. In regards to content, it was felt that providing concise impressions that answer the clinical question first wasmost important. Furthermore, it was stressed that the impression should be at the end of the report. Enhancing report structurewas suggested as a way to improve report clarity and education on the use of multiple well-organized paragraphs was provided tothe staff and residents. Improvement of typographical errors was addressed with transcription services. Also, residents and staffwere reminded to carefully proofread reports. Data was collected and analyzed using univaraiate analysis and statistical comparisonwith a two-sided Student's T-test performed in Excel version 14.3.9 © Microscoft Corp.

RESULTS

Internists scored report content and clarity significantly worse than radiologists (mean content score 1.65 vs. 1.35; p < 0.05),(clarity score 1.74 vs. 1.47, p <0.05), while typographical errors were scored similarly (1.61 vs. 1.56; p = 0.29). Overall, 69% ofrespondents preferred the impression at the end of the report and 25% of respondents read report findings less than 50% of thetime. Following the report improvement plan, no statistical difference was found between content (1.60 vs. 1.65, p = 0.17), clarity(1.65 vs. 1.74, p = 0.053) or typographical error scores (1.55 vs. 1.61, p = 0.11); however, there was a trend towardimprovement.

CONCLUSION

Internists score radiology report content and clarity more poorly compared to radiologists suggesting an interdepartmental barrier tocommunication, while typographical errors scored similarly between groups. Analysis of our data demonstrated a clear preferencefor the impression to be located at the end of the report. This follows classical organization principles and was an important findingemphasizing the need to provide a consistent report structure to clinicians so they can locate pertinent information efficiently,thereby improving communication between the two groups. It was also interesting to note that approximately 25% of respondentsread the report findings section less than 50% of the time. Therefore, there is a high likelihood that imaging findings not highlightedin the impression may not be communicated to the clinician and that the impression section should consistently convey a pertinentsummary of imaging findings and recommendations. After our improvement plan was implemented there was a trend towardsimprovement, but unfortunately no statically significant difference in content, clarity, or typographical error scores. Futureimprovements such as standardized reporting have been proposed, but significant barriers to implementation remain.

ParticipantsMeredith Bowen, BA, Atlanta, GA (Abstract Co-Author) Nothing to DiscloseKimberly E. Applegate, MD, MS, Zionsville, IN (Abstract Co-Author) Nothing to DiscloseNadja Kadom, MD, Boston, MA (Presenter) Nothing to Disclose

PURPOSE

Many radiologists who are about to perform their first QI project do not know where to start and how to navigate the jungle ofmethods and quality improvement tools. Knowing how others have done a QI project from start to finish can help to lower thebarrier of starting the first QI project. Storyboarding is a tool that narrates processes with visuals and can be used to tell the storyof 'My First QI Project'.

METHODS

We used storyboarding, a method used to illustrate a sequence of actions. The steps in creating a storyboard are: 1) Story work(Establish a timeline, identify key concepts to convey to viewers, decide on the level of detail, write a description for each visual),2) Design (Decide what medium to use for the template, sketch thumbnails, add other information, finalize storyboard), and 3) Fine-tuning (arrange characters on visuals, manage scene cuts, improve as you go). This storyboard illustrates the performance of apractice quality improvement project (PQI) using the model for improvement (MFI) and referring to the Institute of HealthImprovement website. The chosen example is a pediatric radiologist who wants to implement a fast brain MRI scan to decrease CTradiation exposure in shunted children. Commercial software was used to create the storyboard (Storyboard That,Storyboardthat.com, Cambridge, MD, U.S.). Graphics were generated with InDesign (Adobe, San Jose, CA, U.S.). Output formatsare iBook (iBooks Author, Apple, Cupertino, CA, U.S.) and PDF files (Adobe, San Jose, CA, U.S.)

RESULTS

This storyboard shows a PQI project from start to finish. The physician in the example uses the Model For Improvement as theimprovement method. Additional steps in the storyboard include also activities mandated for entry into the ABR's personal databasefor MOC part IV.Specifically, the radiologist goes through the following steps: 1) Gaining basic knowledge about the Model ForImprovement, 2) Planning (deciding on a project, deciding whether to do an individual or group project, project title and abstract,picking an Institute of Medicine (IOM) QI area, writing an aim, assembling a team, selecting a metric, using a PICK chart), 3)Current state analysis (making a prediction, usings an Ishikawa diagram, baseline measurement, selecting improvement activities),4) PDSA-cycle (3 PDSA-cycles), and 5) Completion (reflection, project summary).

CONCLUSION

Storyboarding is a feasible method to illustrate the PQI process for a novice to radiology QI. The storyboarding method is easy touse and steps in the process are intuitive.

QS014-EB-SUA

Improving Efficiency of Chest Radiographs after Placement of Peripherally Inserted Central Catheters(PICCs)

Hardcopy Backboard

ParticipantsDavid M. Paushter, MD, Chicago, IL (Presenter) Nothing to DiscloseGregory L. Katzman, MD, Chicago, IL (Abstract Co-Author) Nothing to DiscloseMonica Geyer, MBA, Chicago, IL (Abstract Co-Author) Nothing to Disclose

PURPOSE

The purpose of this study was to explore the utilization of root cause analysis (RCA) in conjunction with Lean techniques tounderstand factors limiting appropriate and timely communication of potential retained surgical objects.

METHODS

We reviewed the factors involved in delayed communication of a surgical foreign body, and utilized lean techniques, includinginformation sharing among multidisciplinary teams to map the value stream, establish process measures and improve flow ofpersonnel and information. We employed a commercially abailable tool to search and aggregate data on pertinent aspects of examordering, performance, interpretation and results communication/documentation to evaluate the success of multiple interventions.These included timing of order, creation of an RFO orderable, requirement for appropriate and specific history in EMR, surgical delayin skin closure, notification of exam readiness to radiologists by visual cues, and templates couples with automatic paging toimprove communication and documentation.

RESULTS

Sequential improvements in compliance were noted with sequentional interventions, with an initial compliance rate of 17%,increasing to full and timely communication and documentation of RFO status in 93% of cases. Sustaining these significant gainsrequires ongoing monitoring and education in a multidisciplinary fashion.

CONCLUSION

Applying Lean techniques to patient safety issues, coupled with RCA can successfully solve problems in a multidisciplinary,collaborative environment without 'shame or blame.' Solutions employed for this particular problem surrounding timely performance,reporting and documentation of RFOs included solutions rooted in Information Technology and alterations in policy and personnelflow to produce significant improvement in outcomes.

ParticipantsJill A. Jones, MD, Kansas City, KS (Presenter) Nothing to DiscloseLucas J. Meek, MD, Roeland Park, KS (Abstract Co-Author) Nothing to DiscloseShaun R. Best, MD, San Diego, CA (Abstract Co-Author) Nothing to DiscloseAmy E. McCann, MD, Kansas City, KS (Abstract Co-Author) Nothing to DiscloseBrandon W. Welsh, MD, Kansas City, KS (Abstract Co-Author) Nothing to DiscloseJacqueline Hill, MPH, Kansas City, KS (Abstract Co-Author) Nothing to DiscloseRyan M. Ash, MD, Kansas City, KS (Abstract Co-Author) Nothing to Disclose

PURPOSE

Bedside placement of peripherally inserted central catheters (PICCs) by specialty-trained registered nurses has become commonpractice at many hospitals and is a valuable alternative to traditional central venous catheters in patients needing prolongedintravenous (IV) access. These nurses are often responsible for all aspects of the PICC procedure, from obtaining informed consentto ordering confirmatory radiographs. At our institution, approximately 500 PICCs are placed at patients' bedside by the IV therapyservice monthly, each one requiring a post-placement chest radiograph to verify catheter tip location. However, there has beenwide variability in the requested radiographic views and the presence or absence of the PICC guidewire on post-placementradiographs. Therefore, this quality improvement study aimed to first identify the best method at our institution for determining thelocation of the PICC tip. Changes to the PICC insertion protocol were then implemented in addition to formal nursing education. Thestudy then evaluated whether or not these changes resulted in a significant difference in the frequency of visualization of the PICCtip or the number of variant radiographic projections requested.

METHODS

Chest radiographs ordered as "Line Placement Verification-PICC" during Q4 2013 (n=592) were retrospectively reviewed by one offive staff radiologists or trained radiology residents. The exams were categorized based on radiographic projection (AP, RPO, both,other), presence or absence of PICC guidewire, and whether or not the original report stated the location of the PICC tip (rightatrium, cavo-atrial junction, superior vena cava, other). Baseline data was analyzed to determine frequency of PICC tipvisualization in each radiographic projection, as well as whether the presence of the guidewire or anatomic location improveddetection of the PICC tip. Results of the initial analysis were then used to implement changes to the PICC insertion protocol in May2014, along with concurrent nursing education. During Q3 2014, PICC verification radiographs (n=577) were evaluated andcategorized in a similar manner by one of the senior radiology residents who categorized the baseline exams. These data werecompared to baseline data using chi-square analyses to determine if there was a significant difference in frequency of PICC tipvisualization and type of radiographic projections following the policy change and education.

RESULTS

Results of the baseline analysis demonstrated that there was no significant difference in the frequency of PICC tip visualization onAP projections as compared to RPO or AP+RPO projections (p=0.160), negating the need for non-standard projections. Thefrequency of PICC tip documentation was greatest when the guidewire was left in place (95%) compared to when it was absent(88%, p=0.002). As a result of these findings, the institutional PICC insertion protocol was modified so that all post-PICCradiographs were to be performed in AP projection only with the guidewire left in place. The IV therapy nursing team was educatedon these policy changes and the underlying rationale in May 2014.Three months after the policy change and education, significantlymore AP projection radiographs were performed, with an increase from 88.0% pre-policy change to 95.7% post-policy change(p<0.001). There was also a correspondingly significant decrease in the number of RPO projection radiographs, from 7.9% pre-policychange to 2.6% post-policy change (p<0.001). The PICC guidewire was also left in place for a larger proportion of studies (82.7%)

compared to baseline (59.1%, p<0.001). When the guidewire was left in place, the catheter tip was visualized in more exams post-policy change (99%) compared to pre-policy change (95%, p=0.004). Additionally, the number of reports recommending repeatimaging decreased from 7 to 1 following the policy modification, although these sample sizes were too small to perform significancetesting. See table 1 for comparison data pre- and post-policy change.

CONCLUSION

Our study demonstrates that by implementing a policy change and providing basic education to the PICC nursing staff, catheter tipdetection can be improved. Reduction in repeat imaging and the number of variant projections will also potentially improve theefficiency of both radiologists and technologists. Additionally, fewer repeat images and oblique views can result in small, butmeaningful, reductions in patient radiation dose.

QS101-ED-SUB1

Decreasing Outpatient Pre-procedure Wait Times in a Pediatric Interventional Radiology (IR)Department: A Software-Solution Enabled Quality Improvement Project

Station #1

QS103-ED-SUB2

A Breast MRI Audit - Are Those Who Need Tt Getting It?

Station #2

QSE-SUB

Quality Storyboards Sunday Poster Discussions

Sunday, Nov. 29 1:00PM - 1:30PM Location: QS Community, Learning Center


Participants

Sub-Events

ParticipantsNeil Shah, MD, Atlanta, GA (Presenter) Nothing to DiscloseC. Matthew Hawkins, MD, Decatur, GA (Abstract Co-Author) Nothing to Disclose

PURPOSE

Accurate scheduling is a challenging aspect of IR practice management. Patients interface with multiple providers in multiple areasof the hospital on the day of their procedure. Variables such as NPO status, lab result availability, and complexity of proceduresperformed earlier in the day impact the ability of IR departments to accurately schedule outpatient procedures. These inaccuraciesincrease patients' pre-procedure wait times. These challenges are exacerbated within pediatric IR departments, where featuresunique to children increase the complexity of preparation, consent, sedation, and recovery. Inaccurate scheduling has potentiallygreater implications for this cohort, as children are often unable to tolerate lengthy pre-procedure wait times.The purpose of thisquality improvement project is to improve outpatient scheduling accuracy within a pediatric IR department by creating andimplementing a scheduling software application informed by baseline data. The goal is to reduce the length of time outpatients waitin our department prior to their procedure by 33% within 15 weeks of implementation.

METHODS

Baseline Data Gathering:We created a process map outlining the steps involved in the outpatient experience in our department,from arrival in waiting to discharge from recovery. We identified 4 locations from which data could be collected:Registration/Waiting Outpatient Preparation Procedure Suite RecoveryWe identified data points to collect, including arrival anddischarge time, pre-procedure preparation data, procedure data, and recovery data.We used Google Forms, Sheets, and Scripts tocreate a data collection tool to gather de-identified data from within our department. The tool allowed real-time data collection bymultiple individuals in fragmented hospital areas. Educational sessions were held with technologists and nurses (the primarystakeholders and data collectors) to describe the initiative and gain buy-in. We collected baseline data for 171 encounters over 7weeks. Our average pre-procedure waiting time for outpatients was 3 hours. We set a goal to reduce pre-procedure wait times foroutpatients by 33% within 15 weeks.Intervention:By convention, our outpatient schedule was handwritten in a datebook, witheach procedure assigned an arbitrary block of time; 1 hour for subjectively short and 2 hours for subjectively long procedures.Patients were instructed to arrive at registration 1 hour prior to their procedure start time, regardless of need for labs/workup.Weused our baseline data to create a smart scheduling application in Microsoft Access that suggests arrival and procedure timesbased on lab draw necessity and procedure time data collected at baseline (stored in a database in the software). The softwarealso constantly updates the database with new patient encounter data (upon completion of an encounter), which compounds uponexisting data to provide up to date arrival and procedure time suggestions.The 1st step in building our software was to create abackend of 3 databases: Procedures: informs procedure time suggestions based on the procedure to be performed and thephysician performing the procedure. Schedule: serves as an electronic replacement for the datebook. Encounters: stores de-identified encounter information consisting of similar data points to those collected in our baseline data gathering phase.Then, wecreated a frontend with 4 main pages: View Schedule Schedule Appointment Delete Appointment Encounter Information: a form toenter information to populate patient encounter databaseWithin the Schedule Appointment tab, the scheduler chooses theprocedure to be performed and answers questions to determine if labs will be needed prior to the procedure. Based on these entriesand other procedures already scheduled for that day, the software suggests outpatient preparation arrival time and procedure startand end times.After a procedure is complete, a member of the team enters encounter information in the "Encounter Information"tab, populating the database with additional information to inform future procedure scheduling.Multiple education sessions were heldwith the technologists in charge of scheduling appointments and entering encounter information. Weekly feedback is provided toteam members involved in scheduling, and opportunities for questions and coaching between the 2 project leaders and thetechnologists are available daily.

RESULTS

After successfully implementing the software for 2 weeks, we have reduced pre-procedure wait time for patients to 2 hours and 15minutes from 3 hours (-25%).

CONCLUSION

By successfully building a software scheduling system informed by baseline data and updated by new patient encounters, wereduced the outpatient pre-procedure wait time by 25% in our pediatric IR department. Weekly feedback reports, coaching, andfurther education sessions will be offered until our goal (33% reduction) is met.

ParticipantsStephanie Tan, MD, Brossard, QC (Presenter) Nothing to DiscloseLucie Lalonde, MD, Mount Royal, QC (Abstract Co-Author) Nothing to DiscloseJulie David, MD, Quebec, QC (Abstract Co-Author) Nothing to DiscloseMona M. El Khoury, MD, Montreal, QC (Abstract Co-Author) Nothing to Disclose

QS105-ED-SUB3

Improving Care and Education through an Assessment of the Impact of a Radiology Resident-DrivenClinical Consultation Service

Station #3

Maude Labelle, MD, Montreal, QC (Abstract Co-Author) Nothing to DiscloseIsabelle Trop, MD, MPH, Montreal, QC (Abstract Co-Author) Nothing to Disclose

PURPOSE

Although breast MRI offers many uses as a highly sensitive exam for breast cancer detection, its limited availability and moderatespecificity require its use to be reserved to patients who would most benefit from it. Indications for breast MRI have been publishedby several associations but there is no formal consensus. A pressing concern is that patients with clear indications for breast MRIare unnecessarily delayed by requests for other women whose gains from MRI are controversial or even unsupported in theliterature.The purposes of our clinical audit were 1. To determine the proportion of breast MRI exams performed at our institutionfor different clinical indications; 2. To assess the waiting times at our institution for non-urgent breast MRI; 3. In light of thesedata, to review the literature regarding breast MRI with our multidisciplinary panel of breast specialists and 4. To draw a list ofevidence-based clinical indications for breast MRI at our university institution that takes into account local capacities for breastMRI.

METHODS

A retrospective audit of indications of all breast MRI performed in September 2013 at our academic center (n=105) was conducted.We also analyzed accumulated requests for breast MRI evaluations awaiting imaging (n=423) and classified them in terms of waitingtime as being within or exceeding prescribed delays as per governmental guidelines (within 90 days for a first request, 30 days for afollow-up evaluation). Third, we invited breast specialists from different fields working at our institution and organized amultidisciplinary half-day meeting in May 2014, during which we reviewed the literature and, based on discussions among the 21physicians present, established a consensus regarding accepted indications for breast MRI. This document was subsequentlyapproved by breast experts from the departments of radiology, surgical oncology, medical oncology, radiation oncology, pathology,genetics and breast physicians. In September 2014, we re-audited breast MRI exams performed during a similar one-month period(n=141) to determine the indications for the exams. In April 2015, we calculated the number of accumulated requests for MRIevaluations awaiting imaging.

RESULTS

In September 2013, the 4 most common indications of 105 breast MRI evaluations were personal history of breast cancer (23%),pre-operative staging (19%), follow-up of MRI findings (17%), and high-risk screening (13%). Of breast MRI requests awaitingimaging at the end of September 2013, 167 were within delays, 132 were waiting less than 6 months, 58 less than 12 months and66 over a year. The multisciplinary session held in May 2014 led to the following recommendations for acceptable breast MRIindications at our institution: 1. screening of high-risk women (excluding women with a personal history of breast cancer, lobularneoplasia or atypia, family history not suggestive of a genetic predisposition and women with dense breasts), 2. preoperativestaging for women with certain types of cancers (infiltrating lobular histology, triple negative receptor expression, Paget's disease,metastatic adenopathy without primary) as well as prior to neoadjuvant chemotherapy, and 3. Problem-solving after inconclusivebreast evaluation after mammography and ultrasound performed at our imaging center. Our standard prescription form for breastMRI was re-written to reflect the new consensus. In September 2014, of 141 breast MRI exams obtained, the proportion of examsperformed for pre-operative staging had decreased from 19% to 9% of all breast MRI indications compared to a year prior, whilehigh-risk screening had increased from 13% to 36% of all exams. As a result, waiting times improved for all breast MRI evaluations,most significantly for high-risk screening. Actuarial projections for the next available non-urgent breast MRI appointment decreasedfrom 19.2 months to 5.9 months.

CONCLUSION

Through multidisciplinary discussion, we actualized a list of breast MRI indications agreed to by all members of the breast center.Application of these guidelines improved the service we could provide to women awaiting breast MRI, particularly those with agenetic predisposition for whom yearly screening is recommended.

Honored Educators

Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifyingeducational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-qualityeducational content in their field of study. Learn how you can become an honored educator by visiting the website at:https://www.rsna.org/Honored-Educator-Award/

Isabelle Trop, MD, MPH - 2014 Honored EducatorLucie Lalonde, MD - 2014 Honored EducatorJulie David, MD - 2014 Honored EducatorMona M. El Khoury, MD - 2014 Honored Educator

ParticipantsGayle R. Salama, MD, New York, NY (Presenter) Nothing to DiscloseCourtney Sullivan, MS, RRA, New York, NY (Abstract Co-Author) Nothing to DiscloseAshley E. Giambrone, PhD, New York, NY (Abstract Co-Author) Nothing to DiscloseJessica Waltz, New York, NY (Abstract Co-Author) Nothing to DiscloseDaniel Holzwanger, MD, New York, NY (Abstract Co-Author) Nothing to DiscloseKeith D. Hentel, MD, MS, New York, NY (Abstract Co-Author) Nothing to Disclose

PURPOSE

Radiology consultation by referring physicians has traditionally been a part of standard clinical practice and reported as a preferredmethod of decision support for imaging. However, PACS technology and current fee-for-service payment models limit directconsultation activities, and the added value of such activities is rarely documented. As healthcare moves towards a bundledpayment system, increasing awareness of the value of the radiologist is essential. Due to time constraints and responsibilities ofattending physicians, radiology residents can provide essential consultation services without significantly disrupting attendingworkflow. Resident-driven clinical imaging rounds (CIR) allow radiologists to actively and directly participate in clinical management,improving care, communication, and education. Consultation activities take considerable time and effort and demonstrating their

QS107-ED-SUB4

Development of a Quality Assurance Program for Breast Magnetic Resonance Imaging CanSignificantly Decrease Defect Rates

Station #4

value impacts future implementation. A retrospective review of survey data determined the qualitative and quantitative effects ofCIR on clinical management, communication, and education of referring providers and radiology residents. With results, CIR will bemodified to better serve patients and providers. Additionally, by documenting its organization and effects, this program can bedeveloped at other institutions to improve patient care and the radiologists' role in the larger medical community.

METHODS

The initial ten months of Clinical Imaging Rounds (CIR) were evaluated in a retrospective study.CIR format: Four 30-minute sessionswere held weekly on the clinical wards. The referring service submitted case requests via email 24 hours before the scheduled CIRtime and provided the patient's identifying data and the focus of the consultation. A radiology resident met with the referringmedicine team to discuss cases. The medicine team presented the relevant patient history. The radiology resident demonstratedrelevant imaging findings, clarified imaging related questions, and discussed management options and recommendations with thereferring service. Residents documented their CIR communication in a standardize note.An anonymous survey was designed forradiology residents and internal medicine attending physicians, residents, and medical students who participated in imagingconsultation rounds to determine the perceived usefulness of CIR as a form of consultation. Qualitative and quantitative analysis ofsurvey responses was performed to demonstrate the impact of CIR on patient care and education.

RESULTS

Approximately 20 radiology residents and 100 internal medicine physicians and medical students participated in imaging rounds. 85%of radiology resident participants completed the survey. Data and evaluation from the internal medicine department survey iscurrently being evaluated.88% of radiology residents believed imaging rounds improves patient care. 87% felt that imaging roundsenhanced their education. 88% reported that CIR improves consultation skills and 93% agreed that imaging consultation roundsimproves communication between the referring service and the radiology department. Preliminary data from internal medicineresponses demonstrate a large majority believes imaging rounds positively affects clinical management of patients, improves patientcare, increases communication between the services, and benefits their education. 100% of radiology and medicine residents whohave responded to the survey thus far expressed a desire to incorporate imaging-medicine consultation into their future practice.Survey participants were given the opportunity to provide free text feedback to identify areas of improvement for CIR.Representative critiques from radiology residents included case submission delays, lack of clarity about the clinical focus ofsubmitted cases, and difficult using Web PACS. Valuable aspects of imaging consultation that were identified by radiology residentsincluded increasing face-time with referring physicians, increasing proximity to direct patient care, improving consultation skills, andlearning through teaching.

CONCLUSION

Resident-driven imaging rounds provides a valuable opportunity to improve communication, education, and patient care. We havecreated a sustainable workflow that allows direct and regularly scheduled imaging-medicine consultation, valued by both radiologistsand internal medicine physicians as an excellent educational experience and a method of improving quality of patient care.Toaddress some of the identified challenges, an automated case submission system is in development. Additionally, improvements inWeb PACS are being made to facilitate remote access to imaging and to allow incorporation of tablet use.Future directions include aretrospective analysis of de-identified patient information obtained from consultation notes authored by the radiology residents todetermine consult patient demographics, nature of consultation, and specific recommendations made during CIR.

ParticipantsSama Alshora, MD, Burlington, MA (Presenter) Nothing to DiscloseStacey Sullivan, RT, Burlington, MA (Abstract Co-Author) Nothing to DiscloseCathleen M. Kim, MD, Burlington, MA (Abstract Co-Author) Nothing to DiscloseJeanette Y. Chun, MD, Burlington, MA (Abstract Co-Author) Nothing to DiscloseMichelle R. McSweeney, DO, Winchester, MA (Abstract Co-Author) Nothing to DiscloseMeera Sekar, MD, Boston, MA (Abstract Co-Author) Nothing to DiscloseAudrey L. Hartman, MD, MS, Burlington, MA (Abstract Co-Author) Nothing to Disclose

PURPOSE

Improve breast MRI quality and decrease number of patient callbacks utilizing Lean and other quality improvement principles.

METHODS

Over a period of 2 months (July-August 2014), 66 breast MRIs were performed, 11 (17%) of which had quality issues as determinedby the reading radiologist. Of those patients, 4 (6%) were so severe that the patient was called back for repeat imaging. A QualityAssurance Program for Breast MRI was developed utilizing general Lean principles and other methods.The key stakeholders wereidentified as 1) the MRI operational manager (RTR) and 2) the Breast MRI section head (MD). These stakeholders developed a ValueStream Map (Figure), identifying 3 major variables: 1) Scanned Documents (e.g. reason for study, LMP, personal and familyhistory), 2) Imaging (e.g. positioning, artifact, signal saturation, motion), 3) 3D post processing (e.g. angiogenesis maps, MIPS,orthogonal reconstructions). They sought out and eliminated "muda" (useless work; waste) related to these steps. Examplesincluded eliminating scanned paper documents that were of little use, and eliminating one MRI sequence, thereby decreasing scantime by 3 min. They identified the worst muda as having to repeat a study because of severe artifact, unacceptable signalsaturation or contrast enhancement, incorrect sequences or severe patient motion. They documented their agreement upon thestandards for study quality in a Quality Assurance for Breast MRI checklist.The technologist who performed the study wasdetermined to be accountable for the items on the checklist. A protocol was established to certify technologists in Breast MRI. TheACR recommends that for a technologist to be Breast MRI qualified, (s)he should have performed 50 breast MRI examinations in theprior 24 months. We data-mined our breast MRI studies, measured the volume over a 2 year span, and broke it out by shift and byindividual technologist. Our volume maximally supported 15 technologists. The key stakeholders selected 15 technologists coveringmost shifts to undergo the certification process. 5 studies from each of these technologists were randomly selected and measuredagainst the checklist. The first several studies were reviewed by both key stakeholders for 'calibration'. Then the MRI operationalmanager reviewed the remaining studies alone. Since different magnets have different imaging protocols, at least 1 study had to befrom each of our 2 magnets. If all 5 studies passed the checklist, the technologist was certified. If any study had a defect in anyoutput variable, the technologist was on probation and had to complete an additional 5 studies defect free under the supervision ofa "Super-tech". 4-5 certified technologists covering most shifts that passed the certification process, showed interest and

QS002-EB-SUB

Using Fast-Track Registration Improves Start Times and Decreases Time-In-Hospital in OutpatientSubcutaneous Ports Placed in the Interventional Radiology Department

Hardcopy Backboard

demonstrated advanced skill as subjectively assessed by the key stakeholders were designated as Super-techs. In addition tosupervising technologists on probation, the Super-techs were available to answer any questions from certified techs.All readingradiologists were active participants. They flagged a study with a defect as either "Hold-do not read" or "Read-with subsequentquality review". The Operational Manager was responsible for resolving any "Hold" issue within 2 hours (e.g. obtaining necessarydocuments, processing study on 3D software, implementing patient call-back procedure) and performing the "quality review" of theother flagged studies on a regular basis.

RESULTS

The percentage of quality issues as well as the rate of patient callback was calculated over a 2 month period after intervention(January-February 2015). A total of 42 studies were performed. The defect rate decreased significantly, from 17% to 2.4%(p<0.02). Due to the small number of patient callbacks, it is difficult to assess the statistical significance of the callback rate.However, the observed incidence rate decreased from 6.1% to 0%.

CONCLUSION

Close communication between the key stakeholders allowed clear delineation of what defined a high quality study. Our volumesupported a large subset, but not the entirety of technologists who had performed breast MRI's. We judiciously removed sometechnologists from the Breast MRI pool, while ensuring the remainder met our high quality study standards covering most shifts. TheSuper- tech model worked well as a resource to and as a support for the frontline techs on all shifts. With the implementation ofthis Quality Assurance program, we markedly decreased our defect rate from 17% to 2.4%, and decreased our muda. To maintainthis high level of quality, we recommend randomly auditing studies from each certified technologist on a yearly basis.

ParticipantsDavid P. Duncan, MD, Louisville, KY (Presenter) Nothing to DiscloseMichael Schacht, MD, Louisville, KY (Abstract Co-Author) Nothing to DiscloseDouglas M. Coldwell, MD, PhD, Louisville, KY (Abstract Co-Author) Consultant, Sirtex Medical Ltd; Consultant, DFINE, Inc

PURPOSE

To study the effect of implementing a fast-track registration process for outpatient subcutaneous venous ports on procedure starttime and overall time spent in the hospital.

METHODS

Patient data were collected using process-flow analysis. A single patient was followed and all events of patient-staff interactionwere recorded. Using this recording, a process map (Figure 1a) and a data collection sheet (Figure 2) were created. Afterevaluating the process map, it was proposed to move registration from the waiting room to the vascular holding area, where itwould occur in parallel with other pre-procedural preparation steps (Figure 1b).A total of 62 patients were evaluated during a 6month period between September 1, 2014 and March 1, 2015. Thirty-three patients registered using the same process as allradiology department imaging examinations and procedures. Registration for this group occurred in the waiting room withregistration priority assigned in the order of arrival. No priority was given to patients undergoing outpatient interventionalprocedures. Twenty-nine patients were assigned to the 'fast-track' registration group. Upon signing in to the radiology departmentwaiting room, this group proceeded directly to the interventional radiology holding area to complete registration. All patients wereassigned a data sheet at time of sign-in and nurses recorded clock time at each data point. The bottom of the page was left blankfor comments regarding potential causes of delay. No personal identifying information was obtained.

RESULTS

Data collected: change of location times; beginning and end times of informed consent; time of IV line placement; laboratory testdrawl and return times; laboratory test type and result. Patient laboratory tests, if required, consisted of coagulation factors andbasic metabolic panels. Causes of delay included a fall, additional procedures, difficult IV line requiring MD or PA assistance, stablepatient without ride home, or missed calls for transport. Collected data were organized on Microsoft Excel. All clock times wereconverted to intervals in minutes. For example, if a patient arrived to the interventional radiolgy holding area at 8:00 AM and laterarrived in the operating room at 9:00 AM, the interval time was recorded as 60. Patients were instructed to arrive 60 minutes priorto appointment time, so all patient arrival times longer than 60 minutes were adjusted to 60 minutes. Arrival times for any patientsigning in less than 60 minutes prior to the scheduled appointment time were left unchanged. Three patients in the control groupand nine patients in the test group (n=12) had incomplete data sheets and were excluded from data analysis.Individual events wereanalyzed between groups to identify and normalize confounding factors when evaluating changes in total time. Only one variable,average processing time for laboratory tests, was significantly different between control and test groups, 38 min vs 53 min [t(23)=-3.0, p=0.0066]. After normalizing the lab values, total time between control and test groups was significantly decreased from anaverage time of 215 min to 178 min [t(37.5)=2.43, p=0.020]. After implementing 'fast-track' registration, the average start timeimproved significantly from an average of 63 min after scheduled procedure start time to 33 min after the scheduled procedure starttime [t(51)=2.7, p=0.009].There were no significant differences in time spent in the vascular holding area, 67 min vs 73 min[t(45)=-0.47, p=0.64], in the operating room, 53 min vs 58 min [t(42)=-1.7, p=0.099], or in the postoperative holding area, 62 minvs 63 min [t(49)=-0.08, p=0.93] between the control group and the test group.

CONCLUSION

The data support our hypothesis that using fast-track registration improves average start time and decreases the total length ofstay for outpatient subcutaneous ports placed in the interventional radiology department. We believe that this improvement resultsfrom a decrease in unutilized time in the radiology department waiting room by moving registration to the interventional radiologyholding area. Registration had to be completed before laboratory blood samples could be drawn. Blood samples were never drawnmore than 5 minutes after IV line placement. Laboratory test results took a noticeably long time to return, averaging 38 to 59minutes to complete. For this reason, laboratory results times are a future target for improvement. In addition, evaluating fast-track registration for other image-guided procedures is warranted.Limitations to our study included some missing fields on the datacollection sheets typically due to the data-recording nurse attending to pressing clinical duties. The variation in lab times betweengroups is particularly intriguing since no identifiable change occurred between groups. In conclusion, implementing fast-trackregistration for outpatient port placement in the interventional radiology department improves start times and decreases the overalltime a patient spends in-hospital.

QS013-EB-SUB

Point of Care Reprogramming of Ventricular Shunts in the MRI Department: Patient Safety andWorkflow Advantages

Hardcopy Backboard

ParticipantsPatrick L. Hanson, Rochester, MN (Presenter) Nothing to DiscloseNorbert G. Campeau, MD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseKarl N. Krecke, MD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseRobert E. Watson JR, MD, PhD, Rochester, MN (Abstract Co-Author) Nothing to Disclose

PURPOSE

To evaluate patient safety and practice workflow advantages of implementing a point of care process to evaluate and resetfrequently encountered programmable shunt setting changes occurring while undergoing MRI examination. While there has beenrecent development of some intraventricular programmable shunts that are unaffected by the magnetic field in MRI, the openingpressure setting of the vast majority of these devices may be inadvertently reset by the strong magnetic fields encountered in MRI.This is a distinct patient safety issue in that failure to reprogram the device properly after MRI could lead to adverse patientoutcomes, including hydrocephalus or over-shunting potentially resulting in emergent conditions of subdural hematoma or brainherniation. Previously, in our practice and the current standard of care in most radiology practices, patients with such shuntsrequired multiple x-rays and appointments with specialists to properly evaluate and reprogram the shunts, requiring patient escortsand significant logistical support. We report on the practice efficiencies and patient safety advantages offered by implementing apoint of care process using appropriately trained onsite MRI personnel to reprogram these devices. Our experience with one type ofshunt, the Medtronic Strata valve, which has greater than 50% of US market share, is described.

METHODS

MRI lead technologists and a radiologist underwent appropriate training for evaluation and adjustment of valve settings frompertinent Neurosurgery personnel and subsequent training visits with Medical representatives from the shunt manufacturer.Subsequent training sessions with practice materials permitted adequate hands-on experience for technologists to gain confidencein their ability to accurately reprogram the devices. Initial direct patient experience included a training period of 2 months duringwhich time patients' devices were initially reprogrammed by the MRI technologists in the presence of a radiologist and subsequentlychecked by experienced Neurosurgery personnel. Over this practice period, no significant discrepancies or need for reprogrammingwas found to be necessary. Subsequently, Strata valve reprogramming has been handled entirely by these trained MRI leadtechnologists.Prior to MRI scanning, the shunt valve is interrogated, and its performance level (corresponding with defined openingpressures) is recorded. Scanning is then performed, following which the device is re-interrogated, and if performance level settinghas changed, it is immediately reprogrammed to its pre-MRI setting. Documentation of the shunt reprogramming is included in theMRI report and electronic medical record.

RESULTS

In the past 14 months, 93 patients with programmable Strata valves were enrolled in this process. The shunt setting changed in78/93 outpatients (84%) and were reprogrammed immediately after completion of the MRI scan by MRI technologists. The averagetime to check and reset the shunt was 4.3 minutes (range 1 to 10 minutes, mode = 4 minutes, standard deviation = 1.9 minutes).Inno cases was shunt reprogramming unsuccessful in this series, eliminating the need for reprogramming by Neurosurgery staff for anyof these patients. There have been no known complications. This process eliminated the radiation exposure for shunt radiographspreviously performed to assess the programmable valve settings before and after MRI. This process provides significant efficiencygains with substantial reduction or elimination of radiography department resources, patient escort resources, and time consumingneed to coordinate reprogramming with Neurosurgery. There are also gains in patient safety in that the need for x-rays (andradiation exposure) is eliminated. Also, the chances of a patient with a changed opening pressure being lost to follow-up arevirtually eliminated.

CONCLUSION

Shunt setting was frequently changed (84%) during the course of an MRI study. This work confirms the merits of having a point ofcare process for evaluation of programmable shunt valve settings and reprogram them if necessary. Substantial MRI practiceefficiency gains and improved patient safety have been realized.

RC129

Should I Scan That Patient? A Very Interactive Session on MR Safety and Regulations (An InteractiveSession)

Sunday, Nov. 29 2:00PM - 3:30PM Location: E353C

HP MR SQ

AMA PRA Category 1 Credits ™: 1.50ARRT Category A+ Credits: 1.50

ParticipantsJeffrey C. Weinreb, MD, New Haven, CT (Presenter) Nothing to DiscloseEmanuel Kanal, MD, Pittsburgh, PA (Presenter) Consultant, Boston Scientific Corporation; Consultant, Medtronic, Inc; Consultant,St. Jude Medical, Inc; Consultant, Bayer AG; Investigator, Bracco Group; Royalties, Guerbet SA;

LEARNING OBJECTIVES

1) Analyze the cause and avoidance of a spectrum of common MR safety issues, including burns. 2) List the factors (includingregulation and guidelines) which should be evaluated in order to determine the safety of MRI in patients with implants, devices, orforeign objects. 3) Answer questions from the audience concerning MRI safety issues

ABSTRACT

The major potential safety considerations in magnetic resonance imaging relate to those stemming from the static magnetic field,the time varying radiofrequency oscillating magnetic fields, the time varying switched gradient magnetic fields, the contrast agentsoften utilized in the MR imaging process, sedation/anesthesia and monitoring-related issues unique to the MR imaging environment,and cryogen related potential safety concerns. These can present confounding situations for MR practitioners faced with questionsrelating to the safety of exposing particular patients and devices, implants, or foreign bodies to MR imaging examinations. Thissession will introduce and briefly explain the above safety considerations, and highlight specific issues likely to confront MRpractitioners in their daily practice by utilizing real-life examples. The methodology and reasoning process used to approach theseclinical examples in determining risk-benefit ratios for accepting or rejecting such patients from MR exposure will be stressed. Theemphasis will be on not so much the particular examples used, but rather having the attendee feeling more comfortable with theapproach to such clinical and research situations in order to better enable them to appropriately address such questions in theirown daily practice routines. Audience polling and interaction will be actively utilized throughout this session. This will help enablethe attendee to not only hear the opinions of the presenters on the cases being discussed, but also to assess their own responsesto the questions being posed relative to that of the other attendees of this session.

RC218A BI-RADS: Why Bother?

RC218B LI-RADS: Pros, Cons and Solutions

RC218C PI-RADS: What Is the Supporting Evidence?

RC218

Have RADS Gone Wild? Remaining Challenges of Standardized Reporting and Data Systems

Monday, Nov. 30 8:30AM - 10:00AM Location: N229

OI IN SQ


Participants

Sub-Events

ParticipantsCarol H. Lee, MD, New York, NY (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Understand the rationale behind the development of BI-RADS. 2) Comprehend the application of BI-RADS in clinical practice. 3)Recognize the contribution of BI-RADS in improving patient outcomes.

ParticipantsClaude B. Sirlin, MD, San Diego, CA (Presenter) Research Grant, General Electric Company; Speakers Bureau, Bayer AG; Consultant,Bayer AG ; ;

LEARNING OBJECTIVES

1) To review the advantages, challenges, solutions, and future directions for standardized reporting of liver imaging examinationsusing LI-RADS.

ParticipantsHebert Alberto Vargas, MD, New York, NY, ([email protected]) (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Understand the rationale for PI-RADS. 2) Highlight the updates included in PIRADS v2. 3) Discuss the evidence basis for PI-RADSand present the literature highlighting its strengths and limitations.

ABSTRACT

The Prostate Imaging Reporting and Data System (PIRADS), published in 2012, was one of the first well-orchestrated effortsfocused on "integration, reporting and communication of multi-parametric prostate MRI". The guideline was updated in 2015 (PIRADSv2) to address some of the limitations of the original version. This session will cover the highlights of PIRADS v2 and discuss thepublished evidence supporting or questioning the recommendations included in this guideline.

RC253A The Unmet Needs of Current and Future Practices

RC253B Augmenting Image Interpretation through the Use of Advanced Health Record Technology

RC253C Bone Age and Skeletal Atlas Decision Support Tools with Patient Context Integrated into ClinicalWorkflow

RC253

Leveraging Your Data: Informatics Approaches and Solutions to Improve Imaging Care Delivery

Monday, Nov. 30 8:30AM - 10:00AM Location: E353A

IN SQ


ParticipantsArun Krishnaraj, MD, MPH, Charlottesville, VA (Moderator) Nothing to Disclose

LEARNING OBJECTIVES

1) Identify unmet needs of current and future practices with regards to emerging and existing informatics tools. 2) Apply existingand emerging informatics applications to improve report generation. 3) Demonstrate an understanding of how best to achieveconsistency of radiologists' recommendations.

ABSTRACT

Existing and emerging informatics applications have the potential to markedly improve the quality of imaging care delivery. Much ofthe inefficiency and inconsistency of report generation could be potentially solved with the appropriate informatics application. Inthis session, the learner will gain an apprecation of the unmet needs of current and future pracitces and discover how novelapplications developed at various institutions across the country are seeking to plug these voids and improve imaging care delivery.

Sub-Events

ParticipantsMichael E. Zalis, MD, Boston, MA (Presenter) Co-founder, QPID Health Inc; Chief Medical Officer, QPID Health Inc; Stockholder,QPID Health Inc

LEARNING OBJECTIVES

1) Describe some of the external mandates and requirements facing practicing radiologists. 2) Describe gaps in function that existbetween these requirements and the functionality provided by EHR and PACS systems. 3) Provide example approaches and examplesolutions to bridge these gaps.

ABSTRACT

ParticipantsArun Krishnaraj, MD, MPH, Charlottesville, VA (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Appreciate the current state of Electronic Health Record (EHR) technology and adoption in the United States. 2) Identify areaswhere EHR integration into the daily workflow of Radiologists is lacking. 3) Demonstrate an understanding of the importance ofincorporating data contained in the EHR to generate high quality reports. 4) Understand the consequences of under utilizing datacontained in the EHR.

ABSTRACT

Advanced heath information technologies, specifically EHR systems, are undergoing rapid dissemination and widespread adoptionspurred by initiatives in the American Recovery and Reinvestment Act of 2009. When properly integrated into clinical workflow, anEHR can improve both the quality and efficiency of care delivery. Radiology has long been at the forefront with respect toinformation technology (IT), however the integration of EHR data into radiolgists' workflow is lacking which affects the efficiency,safety, and costs of Imaging. Emerging advanced heatlh record technologies which incorporate natural language processing andsemantic search allow the radiologists to retrieve and incorporate relevant clinical data when generating reports thereby improvingboth efficiency and quality. In this session, the learner will explore how one such health intelligence platform, known as QPID(Queriable Patient Inference Dossier), allows for the creation of search queries tailored to the workflow of an abdominal radiologist.

ParticipantsCree M. Gaskin, MD, Keswick, VA, ([email protected]) (Presenter) Author with royalties, Oxford University Press; Author withroyalties, Thieme Medical Publishers, Inc; ;

LEARNING OBJECTIVES

1) Review concepts for contemporary decision support tools for diagnostic radiologists. 2) Discuss bone age and skeletal atlasdecision support tools integrated into clinical diagnostic workflow via context sharing.

ABSTRACT

There are numerous references available to radiologists to aid image interpretation or provide guidance on management of imagingfindings. Given the vast amounts of information we are expected to know and the speed with which we are expected to perform our

RC253D Advanced Decision Support Tools for the Radiologists

clinical work, it is helpful to have quick and easy access to relevant resources at our point-of-care (e.g., during imageinterpretation and reporting). Such resources should be available in electronic format on our diagnostic workstations and, whenrelevant, be integrated with our clinical applications. Our Radiology Information System (RIS), PACS, and/or Electronic HealthRecord (EHR) can share study and patient context information with decision support tools to facilitate our diagnostic workflow.Examples to be shared include modern remakes of classic printed atlases in pediatric skeletal imaging, updated to contemporaryelectronic tools integrated with PACS and EHR applications to expedite workflow and reduce error.

ParticipantsGiles W. Boland, MD, Boston, MA (Presenter) Principal, Radiology Consulting Group; Royalties, Reed Elsevier

LEARNING OBJECTIVES

View learning objectives under main course title.

SSC10-01 Size-Specific Fetal Dose Estimates in Tube Current Modulation CT Examinations of Pregnant Patients

Monday, Nov. 30 10:30AM - 10:40AM Location: S504CD

SSC10-02 How Low Can We Go in Radiation Dose for the Data Completion Scan on a Prototype Whole-BodyPhoton-Counting CT System


SSC10

Physics (CT II-Radiation Dose)

Monday, Nov. 30 10:30AM - 12:00PM Location: S504CD

CT PH SQ


FDA Discussions may include off-label uses.

ParticipantsCynthia H. McCollough, PhD, Rochester, MN (Moderator) Research Grant, Siemens AGRobert G. Gould, DSc, San Francisco, CA (Moderator) Research Grant, Koninklijke Philips NV

Sub-Events

ParticipantsKyle McMillan, Los Angeles, CA (Presenter) Institutional research agreement, Siemens AG; Research support, Siemens AG; Maryam Bostani, PhD, Los Angeles, CA (Abstract Co-Author) Research support, Siemens AGErin Angel, PhD, Tustin, CA (Abstract Co-Author) Employee, Toshiba CorporationChristopher H. Cagnon, PhD, Los Angeles, CA (Abstract Co-Author) Nothing to DiscloseMichael F. McNitt-Gray, PhD, Los Angeles, CA (Abstract Co-Author) Institutional research agreement, Siemens AG; Researchsupport, Siemens AG; ; ; ; ;

PURPOSE

Fetal dose estimates have previously been limited to fixed tube current CT exams of pregnant patients. However, in current clinicalpractice, nearly all CT exams are performed using tube current modulation (TCM). The purpose of this work is to develop patientsize-specific CTDIvol-to-fetal-dose conversion coefficients for TCM CT examinations of pregnant patients of various gestationalages.

METHOD AND MATERIALS

For 18 IRB approved pregnant patients of gestational age ranging from 12 to 36 weeks who underwent clinically-indicated CTexaminations, models of maternal and fetal anatomy were created from the image data, and fetal dose was estimated using MonteCarlo simulation of TCM scans of the abdomen and pelvis for a 64-slice MDCT scanner. Predicted TCM schemes were generated foreach pregnant patient model using a validated method that accounts for patient attenuation and scanner limits to determine TCMfunctions for each voxelized model. Fetal doses were normalized by scan-specific 32 cm CTDIvol values based on the average tubecurrent across the entire scan (scanner-reported CTDIvol) to obtain scan technique-independent CTDIvol-to-fetal-dose conversioncoefficients for each patient. Patient size was described using water equivalent diameter (WED) measured at the image containingthe three-dimensional geometric centroid of the fetus. The relationship between the WED patient size metric and CTDIvol-to-fetal-dose conversion coefficients was then examined to determine if a correlation exists.

RESULTS

An exponential relationship between CTDIvol-to-fetal-dose conversion coefficients and patient size was observed with a coefficientof determination of 0.81.

CONCLUSION

For TCM examinations, strong correlation exists between CTDIvol-normalized fetal dose and WED. These results indicate that fetaldose from TCM CT examinations of pregnant patients of various gestational ages may be reasonably estimated with: (a) fetal dosenormalized by scanner-reported CTDIvol to account for scan technique variation and (b) a WED patient size metric to account forpatient size variation.

CLINICAL RELEVANCE/APPLICATION

Results from this work can be used to readily estimate fetal dose for TCM CT exams of pregnant patients given only the scanner-reported CTDIvol and an attenuation-based estimate of patient size.

AwardsTrainee Research Prize - Fellow

ParticipantsZhicong Yu, Rochester, MN (Presenter) Nothing to DiscloseShuai Leng, PhD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseAhmed Halaweish, PhD, Rochester, MN (Abstract Co-Author) Employee, Siemens AGZhoubo Li, Rochester, MN (Abstract Co-Author) Nothing to DiscloseSteffen Kappler, Dipl Phys, Forchheim, Germany (Abstract Co-Author) Researcher, Siemens AGErik L. Ritman, MD, PhD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseCynthia H. McCollough, PhD, Rochester, MN (Abstract Co-Author) Research Grant, Siemens AG

PURPOSE

SSC10-03 Size-Specific Effective Dose Estimates in Abdominal and Chest CT Exams Using Either Fixed TubeCurrent or Tube Current Modulation


SSC10-04 Reconciling Constant-noise versus Variable-noise Automatic Exposure Control Techniques for Multi-

A hybrid (dual-source) prototype CT system (Siemens Healthcare, Germany), which consists of an energy integrating detector(EID) and a photon-counting detector (PCD), is currently under investigation. The field-of-views (FOVs) of the EID and PCDsystems are 500 mm and 275 mm, respectively. For an object larger than 275 mm, the PCD system needs a DCS (data completionscan) using the EID to avoid truncation artifacts. This work aimed to find the lowest possible mAs for the DCS such that imagequality for the PCD system was maintained.


The DCS should have the same kV as, and slightly greater longitudinal coverage than, the PCD scan. Other parameters such as mAscan be freely chosen. A semi-anthropomorphic phantom (lateral width: 38.9 cm) with iodine and bone-like inserts was scanned withthe PCD system using 210 mAs and 140 kV (CTDIvol = 23.21 mGy). Next, a DCS using the maximal available mAs was performed toserve as the image quality reference. Finally, a series of DCS from 10 mAs (the lowest available on the scanner) to 50 mAs atintervals of 5 mAs was acquired. Images were reconstructed using the same slice thickness (2 mm) and reconstruction kernel(D30). The difference in CT number between the PCD images using no DCS or low mAs DCS and that using the reference DCS weremeasured within regions-of-interest (ROI) in the iodine and bone-like inserts, and the water-equivalent material at top, left, center,and right of the PCD FOV. These data were used for CT number accuracy and uniformity analyses. The lowest mAs of the DCS thatmaintained CT number accuracy and uniformity was determined, and further validated with an anthropomorphic torso phantom.

RESULTS

PCD images using a 10 mAs DCS at 140 kV (CTDIvol = 0.93 mGy) were free of cupping artifacts, and had CT number accuracy anduniformity within 1 HU of the reference image. With the 10 mAs DCS, the PCD images of the shoulder, chest, and abdominal regionsof the torso phantom demonstrated equivalent image quality to their reference images. Image quality improvement was limited whena larger mAs (>10) was used in the DCS.

CONCLUSION

DCS using less than 1 mGy is sufficient to maintain clinically viable image quality for PCD scans.


The DCS significantly improve the image quality of the PCD system at a markedly low cost of radiation dose.

ParticipantsKyle McMillan, Los Angeles, CA (Presenter) Institutional research agreement, Siemens AG; Research support, Siemens AG; Maryam Bostani, PhD, Los Angeles, CA (Abstract Co-Author) Research support, Siemens AGLifeng Yu, PhD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseShuai Leng, PhD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseChristopher H. Cagnon, PhD, Los Angeles, CA (Abstract Co-Author) Nothing to DiscloseMaria Zankl, PhD, Neuherberg, Germany (Abstract Co-Author) Nothing to DiscloseCynthia H. McCollough, PhD, Rochester, MN (Abstract Co-Author) Research Grant, Siemens AGMichael F. McNitt-Gray, PhD, Los Angeles, CA (Abstract Co-Author) Institutional research agreement, Siemens AG; Researchsupport, Siemens AG; ; ; ; ;

PURPOSE

Conventional estimates of effective dose do not account for patient size or the effects of tube current modulation (TCM). Thepurpose of this study was to extend that work by developing size-specific effective dose estimates for both fixed tube current(FTC) and TCM abdominal and chest CT scans.


Using detailed Monte Carlo simulations of a 128-slice multi-detector row CT scanner, doses to all radiosensitive organs for eightpatient models from the GSF family of voxelized phantoms and the male and female ICRP adult reference computational phantomswere determined for both FTC and TCM abdominal and chest CT examinations. Patient-specific TCM schemes were generated usinga validated method that accounts for patient attenuation and scanner limits to determine TCM functions for each voxelized model.For abdominal scans, the scan range was set from the top of the liver to the sacroiliac joint. For chest scans, the scan range wasset from the top of the lungs to the top of the kidneys. A summation of organ dose values weighted by the appropriate ICRP 103tissue weighting factors produced an estimate of effective dose for each simulated scan. Effective dose estimates were normalizedby scan-specific 32 cm CTDIvol values to obtain scan technique-independent CTDIvol-to-effective-dose conversion coefficients foreach patient model. In order to estimate patient size, water equivalent diameter (WED) was measured at the center of the scanrange. Correlations between patient size and CTDIvol-to-effective-dose conversion coefficients were then determined.

RESULTS

For all scan scenarios, an exponential relationship between CTDIvol-to-effective-dose conversion coefficients and patient size wasobserved with coefficients of determination ranging from 0.76 to 0.88. When all scan scenarios were evaluated collectively, anexponential relationship was observed with a coefficient of determination of 0.76.

CONCLUSION

Strong correlation exists between CTDIvol-normalized effective dose and WED. Results suggest that a general relationship betweenCTDIvol-to-effective-dose conversion coefficients and patient size may be sufficient to estimate size-specific effective dose forboth FTC and TCM routine body CT examinations.


Results from this work provide a reasonable estimate of effective dose that accounts for patient size and can be applied for FTCand TCM abdominal and chest CT examinations.

vendor Body CT Protocol Optimization


SSC10-05 A New Noise Index-mAs Correspondence System for CT Systems with Model Base IterativeReconstruction (MBIR)


ParticipantsJia Wang, PhD, Stanford, CA (Presenter) Nothing to DiscloseLior Molvin, Stanford, CA (Abstract Co-Author) Speakers Bureau, General Electric CompanyKen Lim, MBA, Stanford, CA (Abstract Co-Author) Nothing to DiscloseHans-Christoph R. Becker, MD, PhD, Stanford, CA (Abstract Co-Author) Nothing to DiscloseDominik Fleischmann, MD, Palo Alto, CA (Abstract Co-Author) Research support, Siemens AG;

Background

Automatic exposure control (AEC) techniques vary across different CT vendors. Some keep image noise constant across all patientsizes, while some allow more noise in larger patients. The variability of vendor-dependent AEC scheme puts a challenge in designingCT protocols across diverse CT systems for consistent image quality and dose. We aim to match the AEC exposure output betweentwo manufacturers by utilizing patient dose metric information.

Evaluation

CT scanner exposure output (CTDIvol), AEC settings (QRM for Siemens CareDose4D or Noise index for GE SmartmA) and patientweight of all adult chest-abdomen-pelvis (CAP) CT scans in one calendar year 2014 were accumulated for three CT scanners(Siemens Definition Flash, GE CT750 HD, and GE LightSpeed VCT) using commercial dose tracking software (DoseWatch, GE). TheAEC driven relationship between CTDIvol and body weight was modeled using patient dose metrics data. The patient population wasdivided into three weight groups: less than 150lbs, 150 to 200lbs, and 201 to 265lbs. For each weight group, the AEC models wereused to determine the optimized noise index settings on GE scanners that match CTDIvol from Siemens CareDose4D.

Discussion

A total of 997, 871, and 453 CAP cases were collected on the Flash, CT750 and VCT scanners, respectively. An exponential curveof CTDIvol vs. weight was fitted for CareDose4D technique with QRM at 200mAs (Fig.a), which is our routine clinical setting withdiagnostically acceptable image quality. On GE scanners with SmartmA technique, the dependence of CTDIvol on weight showsdifferent exponential curves at corresponding NI values (Fig.b-c). The optimized NIs of CT750 were found to be at 31, 37 and 46for three weight groups respectively (Fig.d). The model predicted CTDIvol from two different GE AEC techniques agreed within onestandard deviation of the target CareDose4D curve.

Conclusion

Using dose metric data from a large patient population, AEC from two vendors were modeled to explore the dependence of CTDIvolon patient weight. Model predicted AEC settings provide consistent dose performance between different vendors across a widebody weight range.

ParticipantsDaniel Gomez-Cardona, Madison, WI (Presenter) Nothing to DiscloseKe Li, PhD, Madison, WI (Abstract Co-Author) Nothing to DiscloseAdam Budde, MS, Madison, WI (Abstract Co-Author) Employee, General Electric CompanyMeghan G. Lubner, MD, Madison, WI (Abstract Co-Author) Grant, General Electric Company; Grant, NeuWave Medical, Inc; Grant,Koninklijke Philips NVPerry J. Pickhardt, MD, Madison, WI (Abstract Co-Author) Co-founder, VirtuoCTC, LLC; Stockholder, Cellectar Biosciences, Inc;Research Consultant, Bracco Group; Research Consultant, KIT ; Research Grant, Koninklijke Philips NVJiang Hsieh, PhD, Waukesha, WI (Abstract Co-Author) Employee, General Electric CompanyGuang-Hong Chen, PhD, Madison, WI (Abstract Co-Author) Research funded, General Electric Company; Research funded, SiemensAG

PURPOSE

Given the quantitative relationship between noise variance and exposure level, the Noise Index (NI) allows the operators of clinicalCT systems to establish a quantitative correspondence between the noise magnitude and the mAs before prescribing each scan.The introduction of MBIR to clinical CT systems has fundamentally changed the relationship between noise variance and theexposure level. The purpose of this study was to investigate how to develop a new NI system for MBIR.


An IACUC-approved in vivo swine study and an IRB-approved prospective trial with 110 human subjects were performed. All studieswere performed using a 64-slice CT scanner (Discovery CT750 HD, GE Healthcare) equipped with MBIR (Veo, GE Healthcare). Forthe swine study, six mAs levels ranging from (10 to 290) were used. For the human subject trial, an additional reduced dose (RD)scan was performed immediately after the standard dose (SD) scan for each subject; the specific mAs used for the two scansvaried across subjects depending on patient size and clinical indications. Noise variances were measured by drawing regions ofinterest (ROI) on relatively homogeneous anatomical sites such as the liver. Power-law fittings (σ² = α*(mAs^β)) of the measurednoise variance-mAs plots were performed to explore any deterministic relationship between the two parameters.

RESULTS

For the swine study, the exponent of the power law, β, was -1.0 for FBP and -0.4 for MBIR. Results of the clinical trial wereconsistent with the in vivo animal study: the β value measured in the liver was -1.0±0.10 for FBP and -0.4±0.12 for MBIR, and theβ value measured in fat was -1±0.12 for FBP and -0.4±0.12 for MBIR. The difference in the measured β value between FBP andMBIR was statistically significant (p<0.001). Similar to FBP, the value of the parameter, α, depended on the patient size; for a givensize of 28 cm, α = 1.2x10^5 for FBP and α = 600 for MBIR.

CONCLUSION

SSC10-06 Correlation of Size-Specific Dose Estimates (SSDE) to Mean Dose in the Center of a CT Scan UnderConditions of Tube Current Modulation


SSC10-07 The Effects of Size-Specific Phantom-to-Patient Matching for Monte Carlo Based ComputedTomography Dosimetry


We found it is still feasible to establish a new noise index system for MBIR using an empirical power-law relationship between noiseand mAs.


With the increasing popularity of MBIR in clinical CT, there is an urgent need to develop a new Noise Index system that canprospectively determine the noise magnitude of MBIR images at reduced dose levels.

Honored Educators


Meghan G. Lubner, MD - 2014 Honored EducatorMeghan G. Lubner, MD - 2015 Honored EducatorPerry J. Pickhardt, MD - 2014 Honored Educator

ParticipantsKyle McMillan, Los Angeles, CA (Presenter) Institutional research agreement, Siemens AG; Research support, Siemens AG; Maryam Bostani, PhD, Los Angeles, CA (Abstract Co-Author) Research support, Siemens AGShuai Leng, PhD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseLifeng Yu, PhD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseChristopher H. Cagnon, PhD, Los Angeles, CA (Abstract Co-Author) Nothing to DiscloseMaria Zankl, PhD, Neuherberg, Germany (Abstract Co-Author) Nothing to DiscloseCynthia H. McCollough, PhD, Rochester, MN (Abstract Co-Author) Research Grant, Siemens AGMichael F. McNitt-Gray, PhD, Los Angeles, CA (Abstract Co-Author) Institutional research agreement, Siemens AG; Researchsupport, Siemens AG; ; ; ; ;

PURPOSE

AAPM Report 204 demonstrated that size-specific dose estimates (SSDE) are a reasonable estimate of mean dose in the center ofthe scan range for fixed tube current (FTC) body CT examinations. The purpose of this work is to determine if that conceptextends to tube current modulation (TCM) CT examinations of the chest and abdomen.


For eight patient models from the GSF family of voxelized phantoms, and the male and female ICRP adult reference computationalphantoms, SSDE and mean dose in the center of a scan range were calculated for both abdominal and chest CT examinations underthe conditions of FTC and TCM. TCM schemes were generated using a validated method that accounts for patient attenuation andscanner limits to determine TCM functions for each voxelized phantom. Using Monte Carlo simulations of a 128-slice multi-detectorrow CT scanner, mean dose in the center of the scan range was calculated as the average dose to all voxels of a patient modelover five slices (approximately 25-50 mm depending on the model) in the center of the scan range. Using the methodology outlinedin AAPM Report 204, SSDE was calculated using the CTDIvol value based on the average tube current across the entire scan(scanner-reported CTDIvol), a conversion factor based on the 32 cm diameter body CTDI phantom and a measurement of patientsize in the center of the scan range (water equivalent diameter (WED), calculated according to AAPM Report 220). SSDE and meandose in the center of the scan range were then compared for all combinations of anatomy and tube current type.

RESULTS

For abdominal scans, the average absolute difference between SSDE and mean dose in the center of the scan range for FTC andTCM was 3.46% and 7.12%, respectively. For chest scans, the average absolute difference was 5.51% and 7.48%, respectively.

CONCLUSION

For both abdominal and chest CT examinations using FTC and TCM, SSDE calculated using scanner-reported CTDIvol and anestimate of patient size in the center of the scan range closely matched detailed simulations of mean dose in the center of thescan range.


For both FTC and TCM, SSDE provides an estimate of mean dose in the center of the scan range. This work extends the use ofSSDE as a reasonable estimate of patient dose for FTC and TCM body CT exams.

ParticipantsElliott J. Stepusin, MS, Gainesville, FL (Presenter) Nothing to DiscloseDaniel J. Long, PhD, Gainesville, FL (Abstract Co-Author) Nothing to DiscloseWesley E. Bolch, PhD, Gainesville, FL (Abstract Co-Author) Nothing to Disclose

PURPOSE

Due to the rapid growth in Computed Tomography (CT) use over the past few decades, there has become a clear need foraccurate organ dosimetry. The Monte Carlo method, which is one means of performing CT dosimetry, relies on a computationalrepresentation of a patient (a phantom). The purpose of this study is to compare a previously validated Monte Carlo based CT

SSC10-08 Breast and Lung Dose in Chest CT: A Comparison between Standard, Organ-based TCM and FlashSpeed Protocols in Cadavers


SSC10-09 Development of a Computational Adult Brain Model and Applications to Radiation Dosimetry of BrainStructures during Computed Tomography Examinations

Monday, Nov. 30 11:50AM - 12:00PM Location: S504CD

dosimetry methodology performed on patient-specific computational phantoms (based on segmented patient images) to equivalentdosimetry performed on patient-dependent (matched) phantoms, and reference (50th percentile height and weight) phantoms.


Twenty-seven patient-specific computational phantoms were created based on CT images sets of adult patients (14 male and 13female). Each patient-specific phantom had organ doses calculated based on a previously validated CT dosimetry methodology forfour torso exams (chest-abdomen-pelvis, chest, abdomen, and pelvis) with tube current modulation (TCM). Additionally, organdoses were calculated on five computational phantoms (three size-specific and two reference) and compared, per patient. Thethree matching criteria were: height and weight, effective diameter (AAPM Report No. 204), and water equivalent diameter (AAPMReport No. 220). The two reference phantoms were hybrid computational and stylized (ORNL 2006).

RESULTS

The average magnitude of percent difference in organ dose calculations across all patients and organs was 11.1% for the heightand weight matched phantoms, 12.3% for the effective diameter matched phantoms, 29.2% for the hybrid computational referencephantom, and 35.5% for the stylized reference phantom.

CONCLUSION

Although an inherent error exists in matching a patient to a computational phantom for CT dosimetry, matching the patient to asize-specific phantom has a clear increase in organ dose certainty.


Matching a patient to a size-specific computational phantom will allow for a more accurate assesment of organ doses from acomputed tomography examination.

ParticipantsXochitl Lopez-Rendon, MSc, Leuven, Belgium (Presenter) Nothing to DiscloseGuozhi Zhang, Leuven, Belgium (Abstract Co-Author) Nothing to DiscloseWalter Coudyzer, Leuven, Belgium (Abstract Co-Author) Nothing to DiscloseWim Develter, Leuven, Belgium (Abstract Co-Author) Nothing to DiscloseRaymond H. Oyen, MD, PhD, Leuven, Belgium (Abstract Co-Author) Nothing to DiscloseHilde Bosmans, PhD, Leuven, Belgium (Abstract Co-Author) Co-founder, Qaelum NV Research Grant, Siemens AG Federica Zanca, PhD, Leuven, Belgium (Abstract Co-Author) Nothing to Disclose

PURPOSE

To compare breast and lung dose associated with three chest CT protocols with different tube current modulation techniques.


Three female cadavers with different BMI (underweight, normal and overweight) were scanned with a Siemens Definition Flash CTscanner using a Standard chest protocol (3D TCM), XCare (organ-based TCM) and Flash (3D TCM flash speed), all at 120 kVp andwith the CTDIvol of all protocols matched to the patient specific CTDIvol of the Standard examination. The doses to the lungs andbreasts were calculated with a MC simulation framework (EGSnrc) for each voxel model of the cadavers, created by segmenting theCT images. To obtain the tube current modulation information for the different protocols, the raw projection data were collected(xyz modulation). Tube current modulation curves were compared and the dose percentage differences between the standard(reference) and the two other protocols (XCare and Flash) were calculated.

RESULTS

Tube current modulation profiles showed large differences between the three protocols and depended on patient BMI. Both breastand lung doses associated with the XCare and Flash protocols were lower than the doses associated with the Standard protocol forunderweight and normal size. The maximum dose reductions for the lungs for the XCare and Flash protocols were respectively 8.3%and 39.3%; dose reductions for the breast were 13.8% and 45.3%. For the overweight size, we observed a reduction in lung dosefor both protocols with a maximum of 37.2%. Breast dose reduction was 41.8% for the Flash protocol but we found an increase of3.6% for XCare.

CONCLUSION

The tube current modulation scheme of each protocol, as well as the patient habitus, have a strong impact on organ doses. TheFlash protocols reduced dose to the lungs and breast for all sizes and with the highest percentage (max 39.3% and 45.3%,respectively). This is related to the fact that the total mAs used for the examination is lower (34% on average) for the sameCTDIvol. XCare slightly reduced breast dose for underweight and normal size patients but increased it for the overweight patient.


Flash protocol reduces lung and breast dose more than XCare when compared to the standard protocols. Depending on the clinicalindication and image quality needed Flash protocol might be preferred.

ParticipantsNelia Long, PhD, Victor, NY (Presenter) Nothing to DiscloseElliott J. Stepusin, MS, Gainesville, FL (Abstract Co-Author) Nothing to DiscloseDaniel J. Long, PhD, Gainesville, FL (Abstract Co-Author) Nothing to Disclose

Kathleen Egan, Tampa, FL (Abstract Co-Author) Nothing to DiscloseWesley E. Bolch, PhD, Gainesville, FL (Abstract Co-Author) Nothing to Disclose

PURPOSE

The purpose of this study was to calculate sub-region radiation doses within the brain for an array of head/brain CT imagingprotocols. Although methods that use an estimated average whole brain dose may be sufficient to estimate risks using the currentstochastic risk models, they may not be sufficient in future radiation epidemiology risk studies that require absorbed radiation dosesto specific brain sub-regions thought to be associated with brain cancer induction.


Computational brain models of reference adult male and female patients were constructed. A total of 43 different brain sub regionsseparated by hemisphere were created. Radiation doses to the different sub regions in the brain during CT examinations werecalculated using computational models of three CT scanners of varying manufacturer using Monte Carlo particle transportationmethods. Considerations were made for simulation settings regarding gantry angle, scan length, beam energy, filtration, collimation,pitch, and starting angle.

RESULTS

Differences between an individual brain sub-region and the averaged brain dose can be substantial (up to 140%) depending uponthe protocol being studied. Depending on the exam taking place some brain structures may not be included in the primary x-raybeam. As a result, out-of-field structures receive doses that are lower than given by the average brain dose. On the other hand,structures that are entirely in the primary beam and therefore receive the bulk of the radiation field energy deposition receive dosesthat are significantly higher than the calculated whole brain dose.

CONCLUSION

The average brain dose, depending on the application, may not always be a true representation of the dose to the tissues fromwhich glioma, meningioma, or other types of central nervous system cancers arise. The moderate dose gradients across the brain,as well as the anatomical coverage during a CT exam are two of the main factors that influence these differences.The dosedatabase developed in this study can be used in future epidemiology studies that require estimates of absorbed radiation doses tospecific brain structures rather than to the entire brain.


Average brain dose may not be sufficient for radiation epidemiology studies that require absorbed radiation doses to specific brainsub-regions thought to be associated with brain cancer induction.

QS108-ED-MOA1

Multidisciplinary Interventional Radiology Simulation Day to Improve Team Communication andPatient Safety

Station #1

QS110-ED-MOA2

Use of Standardized Templates to Decrease Errors of Technique Description in Radiology Reports

Station #2

QSE-MOA

Quality Storyboards Monday Poster Discussions

Monday, Nov. 30 12:15PM - 12:45PM Location: QS Community, Learning Center


Participants

Sub-Events

ParticipantsNoy Bassik, MD, PhD, New York, NY (Presenter) Nothing to DiscloseRonald S. Winokur, MD, New York, NY (Abstract Co-Author) Nothing to DiscloseEllen E. Bridges, RN, BS, New York, NY (Abstract Co-Author) Nothing to DiscloseMaya E. Hartman, MD, New York, NY (Abstract Co-Author) Nothing to DiscloseRichard H. Marshall JR, MD, New Orleans, LA (Abstract Co-Author) Nothing to DiscloseTheresa Salerno, New York, NY (Abstract Co-Author) Nothing to DiscloseJamie Stern, BA, New York, NY (Abstract Co-Author) Nothing to DiscloseJessica Waltz, New York, NY (Abstract Co-Author) Nothing to DiscloseJimmy Ng, New York, NY (Abstract Co-Author) Nothing to DiscloseBradley B. Pua, MD, New York, NY (Abstract Co-Author) Nothing to Disclose

PURPOSE

This poster seeks to describe the implementation of our multidisciplinary Interventional Radiology (IR) simulation day utilizing limitedcost and resources. In medicine, simulation is used as a tool to train and evaluate staff, prepare for and normalize emotionallyintense situations, and practice low frequency events. Simulation in IR deserves special attention due to the large specializedequipment and radiation exposure risk. The goal of our simulation event was to improve division safety by strengthening IR teamdynamics and communications skills, and to introduce an angiographic simulator to practice infrequent procedures, potentiallycreating a safer patient environment. We accomplished this by extending simulation based on tasks (such as a biopsy) to acompetency based observational simulation involving an entire patient encounter.

METHODS

A multidisciplinary team including attending IR physicians, residents, radiology technologists, nurses, and a clinical nurse practitionermet to design a case-based simulation day. The simulation day was designed to operate within the physical space of the IRdepartment while preserving inpatient clinical operations. Multidisciplinary teams rotated between participating in a simulation,observing a simulation, and working in a clinical room, which necessitated developing a schedule specifying the planned activitiesfor every clinical worker throughout the day.Detailed scenarios were designed with a complete history and physical, consent forms,clinical notes, and imaging available for review when requested. Involvement of nurses and technologists ensured that every step,including requisition forms, equipment setup, and time-outs was optimized to challenge and simulate a real case. The participantswere provided with a brief history and the procedure requested, additional information was available only on request frommoderators. One simulation room utilized an endovascular simulator to stage the angiography component. Commercial software wasused to provide continuous vital signs and each scenario used a standard CPR mannequin, a standard procedure tray, and real butexpired catheters/wires. Two case based scenarios were developed: the first involved placement of a nephrostomy tube in apatient urgently transferred from the emergency department, with an inadequate handoff. The second case was an electiveoutpatient iliac artery stent placement. Both cases involved unexpected complications and were designed to evolve based onchoices the teams made in real time, with guidance from the moderator. Extensive effort was put into developing a patient behindeach case, and mapping out decision trees and outcomes for participants.Multiple steps were crucial to the day's success, such asa practice simulation day, introductory lectures, and video recording of the actual simulations for later analysis. A debriefing sessionfollowing simulations proved useful for departmental improvement.

RESULTS

All teams successfully completed both scenarios and navigated the planned challenges. Pre and post activity Likert Scale surveyswere used to poll all 42 participants and revealed positive responses to Simulation Day. 82% agreed that "Simulation Day made youmore comfortable with voicing your concerns within your healthcare team", (rising from 3.7 to 4.3 on a 5 point scale). Debreifingand review of simulations resulted in opportunities for departmental quality improvement in areas such as standardization ofantibiotic choices, and clinical deteriorations where more assistance was needed.

CONCLUSION

We hope this scheme may serve as a guide to other interventional radiology departments in implementing a low-cost simulationintegrating all aspects of the care delivery team. Successful implementation of a case based simulation curriculum in our working IRdivision involved all staff and was met with positive responses. The simulation day resulted in improved staff confidence regardingcommunication and emergency situations, and allowed for a feedback loop that improved several aspects of patient safety. Clipsfrom the video recordings are now available for use in staff training and as examples of good team communication, as well as ademonstration of a well run code in an angiographic suite.The success of this model was enabled by involving all members of the IRteam throughout the planning stages, by creating detailed case scenarios, and by scheduling the simulation and clinical workflowfor every individual throughout the day. All members of the team are critical to the care of each patient and the implementation ofa multidisciplinary simulation curriculum will allow everyone to be prepared for infrequent life threatening situations resulting inimproved patient outcomes and patient safety.

QS112-ED-MOA3

Reducing Functional MRI Scan Times by Optimizing Workflow

Station #3

ParticipantsThomas J. Reilly JR, MD, Philadelphia, PA (Abstract Co-Author) Nothing to DiscloseRyan K. Lee, MD, Philadelphia, PA (Abstract Co-Author) Nothing to DiscloseChristopher E. Kim, MD, Philadelphia, PA (Presenter) Nothing to Disclose

PURPOSE

The purpose of this institutional quality improvement project was to decrease the number of errors in the reporting of theradiographic technique (i.e. number and specific radiographic views) in radiology reports throughout our health system.Incongruence of the reported views obtained and the actual views obtained are problematic for several reasons. First, it can callinto question the validity of the entire report including whether or not the report refers to the correct patient. Secondly, itgenerates requests to the radiologist for addendums which in turn results in more work not only for the radiologist, but also thetechnologist, and billing department, who must identify these errors. As such, the ability to decrease the frequency of thesemismatches would both improve workflow and accuracy of billing.

METHODS

Once a radiographic study is completed by the technologist and finalized by the radiologist, it is sent for billing. Studies can bemarked for additional review by the billing department due to a variety of reasons, including: insufficient history/clinical informationrelated to a billable diagnosis, left/right discrepancy and incomplete or non-diagnostic studies. However, at our institution thenumber one cause of studies marked for review by the coders was a mismatch between the radiographic technique stated in theradiologist's report and the assigned billing code.Our quality improvement journey first began with collecting data from the coders.We reviewed all radiographic studies marked for review by the coders starting in January 2014 and continuing throughout the year.We tracked the total number of studies marked for review as well as the subset of studies flagged for review due to mismatches ofreported radiographic technique versus due to questions regarding the assigned billing code.The foundation of the process ofimproving the workflow and decreasing mismatches began with standardization. First, we created a set of report templates whichall radiologists would agree to use. Study specific radiology report templates were created for all radiographic plain film examinationswithin our dictation program. This involved the large task of mapping every possible procedure code to a matching template as thedefault. These reports were then vetted for formatting, grammar and content by department section heads. In order to promoteradiologist compliance, we made these new templates the default templates to use. This ensured that when a radiologist initiated adictation, the system template we created would automatically pop up.Continuing with the theme of standardization was theimplementation of auto-populating the technique of the study. This was accomplished by directly importing the billing description ofthe study directly into the template. By auto-populating the technique in this fashion, we take away the necessity of theradiologist to manually dictate the technique, and as a result remove a possible source of error.

RESULTS

The system wide default radiographic report templates with the automatically populating technique section were instituted on10/30/2014. We reviewed monthly coding worksheets from 1/1/2014 through the end of February 2014. This gave us data for 10months prior to the use of the template and 4 months following the implementation. In the 10 months prior to implementing thetemplates the average number of total studies marked for review was 99.9 (range=69-162; median=90) and the average number ofcases addended for technique was 51.9 (range=32-76; median=50). After the templates were instituted the average total numberof studies marked for review decreased to 39.25 and the average number of cases addended for technique decreased to 7.75.Using a student t-test the reduction in both the total number of cases marked for review and the number of cases addended fortechnique reached statistically significance (p-value = 0.0025 and 0.000003, respectively).

CONCLUSION

The implementation of system wide default radiology report templates with the technique section automatically populating theradiology report from the billing description resulted in a dramatic, statistically significant decrease in the total number ofradiographic examinations marked for review by our billing coders as well as the total number of addendums to reports issued for thepurposes of correcting or clarifying technique to match the billing code. This quality improvement project improves the quality andaccuracy of our radiograph reports while increasing efficiency and accuracy of our department's billing.

ParticipantsWilson B. Chwang, MD, PhD, Stanford, CA (Presenter) Nothing to DiscloseMichael Iv, MD, Stanford, CA (Abstract Co-Author) Nothing to DiscloseDarryl Costales, RT, Palo Alto, CA (Abstract Co-Author) Nothing to DiscloseJason Smith, BSRT, Stanford, CA (Abstract Co-Author) Nothing to DiscloseTeresa Nelson, Stanford, CA (Abstract Co-Author) Nothing to DiscloseAleksandrs Kalnins, MD, MBA, Stanford, CA (Abstract Co-Author) Nothing to DiscloseJake Mickelsen, BS, Stanford, CA (Abstract Co-Author) Nothing to DiscloseRoland Bammer, PhD, Stanford, CA (Abstract Co-Author) Founder, iSchemaView, Inc; Director, iSchemaView, Inc; Stockholder,iSchemaView, IncDominik Fleischmann, MD, Palo Alto, CA (Abstract Co-Author) Research support, Siemens AG; David B. Larson, MD, MBA, Los Altos, CA (Abstract Co-Author) Intellectual property license agreement, Bayer AG; Potentialroyalties, Bayer AGMax Wintermark, MD, Lausanne, Switzerland (Abstract Co-Author) Advisory Board, General Electric Company; Michael M. Zeineh, PhD, MD, Stanford, CA (Abstract Co-Author) Research funded, General Electric Company

PURPOSE

Functional MRI (fMRI) is a complex, specialized examination that requires extensive patient interaction as well as the coordinatedefforts of the entire health care team. We observed that in our practice, fMRI studies were being conducted inefficiently, leading tolengthy scan times. The purpose of our project was to reduce fMRI scan times by increasing the efficiency of our workflow.Reducing fMRI scan times has many implications for patient care, potentially having direct and indirect benefits. Directly, workflowefficiency is increased, and patient comfort and satisfaction is increased by not having to lie in the scanner for an unnecessarilylengthy period. Indirectly, conducting shorter fMRI scans can result in either cost savings, or increased revenue by using the extratime to perform additional MRI scans that could not otherwise be done. Our specific goal was to consistently reduce fMRI scan

QS114-ED-MOA4

Multi-Disciplinary Guideline Results in Improved Magnetic Resonance Imaging Utilization for Childrenwith Musculoskeletal Infection

Station #4

times from a median time of 74 minutes to 60 minutes or less. We began our project in October 2014, and set an initial targetcompletion date of April 2015, or approximately 6 months from our start date.

METHODS

We assembled a multidisciplinary team of Radiology faculty, fellows, technologists, administrators, and quality improvementmanagers. We conducted multiple cycles of plan-do-study-act (PDSA) using standard quality improvement tools and metrics. Toanalyze our current state, we retrospectively reviewed all fMRI exams performed at our institution from January 2013 to October2014. We calculated the scan time of each individual exam using acquisition times of the first and last sequences, and plotted thescan times on a run chart. We performed root-cause analysis, using a fishbone diagram to visualize factors contributing to lengthyfMRI scan times. We then identified key drivers, which were 1) streamlined protocols, 2) consistent patient monitoring, 3) clearvisual slides and audio, 4) improved patient understanding, and 5) minimized patient motion. Specific interventions to address eachof the key drivers were 1) eliminating intravenous contrast, 2) reducing repeated language paradigms, 3) updating technologistchecklists for patient monitoring, 4) updating visual slides and audio, 5) developing a patient training video, and 6) developingmultilingual paradigms. We continued to track our fMRI scan times from October 2014 to April 2015, plotting these on our annotatedrun chart. As a balancing measure, we reviewed each fMRI exam to determine whether it was of diagnostic quality, defined aswhether the report answered the primary clinical question. This was done to ensure that the quality of the exams was not beingsacrificed as scan times were reduced.

RESULTS

We performed 89 fMRI exams from January 2013 to April 2015. One exam was excluded since the patient was unable to completethe study. For the remaining 88 exams, the mean scan time was 73 minutes, median was 70 minutes, and range was 27 minutes to148 minutes. The standard deviation was 21 minutes. Our project run chart is shown in Figure 1. We implemented four specificinterventions. The outcomes data met criteria to indicate a shift in the process median on November 28, 2014. Prior to this date,there were 72 fMRI exams which had a median scan time of 74 minutes. After this date, there were 16 fMRI exams (excluding one)which had a median scan time of 59 minutes. Of the first group of 72 exams, 26 (36%) had contrast-enhanced sequences, and 33(45%) had every language paradigm repeated. 57 exams (79%) in the first group were of diagnostic quality. The 15 nondiagnosticexams were due to patient motion, inability to cooperate with instructions, or communication barrier. Of the second group of 16exams, none had contrast-enhanced sequences, and none had every language paradigm repeated. However, 9 (56%) had at leastone paradigm repeated for either technical or diagnostic reasons. 13 exams (81%) in the second group were of diagnostic quality.The 3 nondiagnostic exams were due to patient motion, difficulty performing the tasks, or artifact from braces.

CONCLUSION

Optimizing functional MRI workflow is an important part of our health care mission in diagnostic radiology. By implementing specificinterventions to improve our workflow, we successfully reduced our median fMRI scan times from 74 minutes to 59 minutes. At thesame time, the majority of our fMRI exams remained of diagnostic quality. In the future, we plan to add more interventions, such asdeveloping a patient training video and developing multilingual paradigms, which will address our remaining key drivers. We believethat these interventions will be sustainable over time, and that the process of workflow optimization can be applied broadly to anyfunctional MRI practice.

Honored Educators


David B. Larson, MD, MBA - 2014 Honored Educator

ParticipantsJeannie K. Kwon, MD, Dallas, TX (Presenter) Nothing to DiscloseAndrew Mueller, BS, Dallas, TX (Abstract Co-Author) Nothing to DiscloseVineeta Mittal, MD, Dallas, TX (Abstract Co-Author) Nothing to DiscloseJeffrey Steiner, DO, Dallas, TX (Abstract Co-Author) Nothing to DiscloseNeil J. Fernandes, MD, Dallas, TX (Abstract Co-Author) Nothing to DiscloseEduardo Lindsay, MD, Dallas, TX (Abstract Co-Author) Nothing to DiscloseChan H. Jo, Dallas, TX (Abstract Co-Author) Nothing to DiscloseLawson A. Copley, MD, Dallas, TX (Abstract Co-Author) Nothing to Disclose

PURPOSE

Magnetic resonance imaging (MRI) is increasingly viewed as the gold standard to guide the evaluation and treatment ofmusculoskeletal infection (MSKI). When performed under sedation in the pediatric population, utilization of this resource requiresmulti-disciplinary coordination for safe, timely and efficient use. A multi-disciplinary guideline was developed, with continuousprocess improvement focused on the decision to obtain and schedule MRI, communication of results of the MRI, and subsequentmanagement, including same-day/same-anesthesia surgery. The purpose of this study is to evaluate the impact of guidelineimplementation for sedated MRI at a tertiary pediatric medical center.

METHODS

A multi-disciplinary MRI with sedation guideline was implemented at our institution. Children suspected of having MSKI wereadmitted to a multi-disciplinary hospital service, which held daily morning care conferences attended by the patient's family,pediatric hospitalist, orthopedic surgeon, nurse, physical therapist, and social worker. Decision to obtain MRI was made by thegroup based on standard clinical information. MRI was scheduled during the mid-day safety capacity time slot, which was createdto give priority to MSKI cases. Prior to MRI, the orthopedic surgeon directly communicated with the anesthesiologist and radiologistregarding the patient assessment and plan, with the objective of facilitating prompt MRI result communication to allow forcoordination of same-day/same anesthesia surgery, if indicated based on MRI results. Scan duration, number of sequencesperformed, timing of surgical intervention, length of hospital stay (LOS), and readmissions were compared in cohorts of children who

QS003-EB-MOA

Patient-Centric Improvement Project: Streamlining Workflow Processes to Improve Efficiency ofUltrasound-Guided Procedures

Hardcopy Backboard

had been treated prior to and following guideline implementation. Program surveillance with ongoing feedback to the keystakeholders was performed for an additional year. Comparative data was gathered for the subsequent cohort to determine anyimpact of the continued process improvement program on MRI utilization. Statistical comparison was performed to determinesignificant differences between groups.

RESULTS

Children evaluated prior to the guideline implementation (n=249) had 9.0 MRI sequences per scan, MRI scan duration of 111.8minutes, and LOS of 7.5 days. In comparison, children in the initial MRI guideline cohort (n=512) had 7.5 sequences per scan, scanduration of 75.3 minutes, and LOS of 5.4 days. Children in the subsequent guideline cohort (n=496) had 6.5 sequences, scanduration of 56.0 minutes, and LOS of 5.0 days. The rate of immediate surgery under continued anesthesia was 16.7% prior to theguideline, 50.5% among children in the initial guideline cohort and 64% among children in the subsequent guideline cohort.Differences between cohorts were significant (p<0.0001). In aggregate, 264 hours of MRI scan time and 809 hospital bed dayswere conserved over 30 months.

CONCLUSION

A multi-disciplinary, MRI with sedation guideline for children being evaluated for musculoskeletal infection resulted in improved MRIutilization, improvement in timeliness of surgery immediately following MRI under the same anesthesia, and fewer hospital bed days.This initiative led to improvement in diagnostic efficiency, therapeutic consistency, and patient safety for children withmusculoskeletal infection.

ParticipantsSamir Budimlic, MS, Rochester, MN (Presenter) Nothing to DiscloseStacy R. Schultz, BA, Rochester, MN (Abstract Co-Author) Nothing to DiscloseRoyce Ruter, Rochester, MN (Abstract Co-Author) Nothing to DiscloseRyan Karshen, ARRT, Rochester, MN (Abstract Co-Author) Nothing to DiscloseJohn M. Knudsen, MD, Rochester, MN (Abstract Co-Author) Nothing to Disclose

PURPOSE

In a collaborative effort between the Departments of Radiology and Nursing, a multidisciplinary group of front-line staff sought toidentify existing inefficiencies in our ultrasound procedure practice and reduce their negative impact on the patient experience.Following the Six Sigma DMAIC (Define-Measure-Analyze-Improve-Control) methodology, the group set out to implement changesaimed at improving workflow processes to increase efficiency. As a result of the initial analysis, three objectives were identified: (1)unify all outpatient procedure workflows, (2) reduce the overall procedure lead time, including the pre-procedure preparation, by20% and (3) improve the morning on-time procedure start rate to 30%.

METHODS

During the define phase, the team developed a project charter and used standard quality improvement tools including a stakeholderanalysis and value stream maps of the current state. In the measure phase, data collection sheets were used along with the valuestream maps to identify metrics. The team decided to focus on two metrics as project goals: (1) total lead time, defined as a sumof pre-procedure preparation and procedure time and (2) morning on-time procedure start time rates, defined as electronic timestamp for sonographer procedure start equal to or prior to patient scheduled appointment time. For the analyze phase, a Paretochart identified those process steps which would provide the greatest impact during the improvement phase. Then, an affinitydiagram was used to collect and categorize improvement ideas. Team members voted to identify those ideas they felt would havethe greatest impact. Utilizing an impact/effort grid, the team narrowed the focus to those improvements that yielded the greatestvalue/impact ratio. During the improve phase, changes to the existing process were tested by developing and performing multiplePlan-Do-Study-Act (PDSA) cycles. The impact of the changes was documented through qualitative and quantitative data collectionand then compared to the baseline data.The team developed a communication plan to help with change management. This planincluded e-mail communications, presentations at staff meetings for all impacted stakeholders and point-of-care instruction witheducation when necessary.

RESULTS

Our first PDSA cycle focused on improving outpatient deep tissue biopsy workflow as a target with the greatest potential valuetowards meeting our goal. By modifying the workflow to eliminate the need for patients to check into our outpatient hospitaladmission floor for their pre-procedure work-up, the total lead time for this subgroup of outpatient procedures improved from 200 to127 minutes (35%). This change also standardized outpatient procedural workflows as all patients now followed the same check-inprocess. Our second PDSA cycle involved revising sonographer and procedural RN roles at the beginning of the day. This processchange improved morning on-time procedure start rate from 18% to 34%. Lastly, our third PDSA cycle focused on utilization of aback-up procedure room for low risk procedures that do not require pre-procedural nursing assessment. In-room procedural supportwas provided by an existing unlicensed procedural assistant. This process change allowed additional flexibility, further reducing thetotal lead time and procedure start time delays. In the end, the total lead time for all ultrasound procedure patients was reducedfrom 135 minutes to 101 (25%) and the morning on-time start rate was improved from 18 % to 45%. Qualitative feedback alsoshowed improvement in both patient and staff satisfaction.

CONCLUSION

The 11-month, interdepartmental, collaborative, quality improvement effort using the DMAIC framework was successful in improvingthe department's efficiency by reducing unnecessary redundancies, decreasing delays and streamlining workflow processes. Wesucceeded in meeting our objectives of unifying the outpatient procedure workflows, reducing the total lead time for all proceduresand improving the morning procedure on-time start rate.

QS001-EB-MOA

Restructuring Radiology Resident Morbidity and Mortality Conference: A New Approach to PromotePatient Safety through Creation of a Just Culture

Hardcopy Backboard

ParticipantsKelsey Flynt, MD, Ann Arbor, MI (Presenter) Nothing to DiscloseTim I. Alves, MD, Ann Arbor, MI (Abstract Co-Author) Nothing to DiscloseMatthew S. Davenport, MD, Cincinnati, OH (Abstract Co-Author) Book contract, Wolters Kluwer nv; Book contract, Reed Elsevier; Ella A. Kazerooni, MD, Ann Arbor, MI (Abstract Co-Author) Nothing to DiscloseJanet E. Bailey, MD, Ann Arbor, MI (Abstract Co-Author) Nothing to Disclose

PURPOSE

Our traditional diagnostic radiology resident Morbidity and Mortality Conference (MandMC) format was designed to presentanonymous cases for the explicit purpose of error recognition and mitigation; however, this format does not encourage individualaccountability and promotion of a just culture in which open discussion of errors by those involved is encouraged and supported.We decided to review and restructure the format and approach of the MandMC from a traditional anonymous case review to a newclinical outcome-focused presentation by residents involved directly with each error. The goal was promotion of a "just culture,"which can be described as a blameless culture that encourages individuals to bring forward errors, misses, and near misses so thatwe can learn from our mistakes without assigning individual blame or shame, and doing so with the positive mindset of continuousiterative improvement in the healthcare we provide.

METHODS

We analyzed the frequency and format of the traditional diagnostic radiology residency MandMC performed at our quaternary caremedical center and compared it to the MandMCs performed by clinical specialties, most notably surgical disciplines. Next, wechanged the presentation style of the MandMC to reflect those philosophies that we thought valuable in encouraging personalaccountability, promoting a solutions-oriented approach, and highlighting system-based problems. Then, we increased thefrequency of our MandMC to increase mindfulness of the important concepts towards achieving a just culture. Informal polling ofthe radiology residents was performed at the first restructured MandMC to determine initial perceptions of how MandMC washistorically performed. Finally, we more formally surveyed the radiology residents after three restructured MandMCs had beencompleted.

RESULTS

The traditional radiology resident MandMC was given approximately once per year with all cases presented by chief residents in ananonymous manner without involvement of the resident to which the error was attributed. During these conferences, on-call caseswith a final report that was discordant from the preliminary resident interpretation were shared and teaching points from these"missed cases" were highlighted. This was in stark contrast to non-radiology MandMCs, which are more patient-oriented and placeemphasis on provider accountability. Informal polling of the radiology residents was performed at the first restructured MandMC withabout 50% of all residents in attendance. Following the change of conference style, the residency was surveyed more formally with26 residents (60%) responding. Prior to changing the conference frequency and format, 100% of residents attending the initialrestructured MandMC indicated that radiology resident MandMCs were too infrequent, leading to missed opportunities for learning.After 3 restructured MandMCs, 100% of the residents responding to the follow-up survey preferred the more frequent MandMCs. Ofthe residents responding to the follow up survey, only 27% of residents felt that the current departmental culture activelypromoted a culture of learning from mistakes to improve patient care. However, the majority (77%) of residents indicated thatwhen the resident involved with the case presents to the group, the stigma of discussing medical error was decreased, and theoverwhelming majority (81%) of residents reported trusting the competency of the residents presenting the errors.

CONCLUSION

Restructuring the diagnostic radiology resident Morbidity and Mortality Conference format promoted both personal accountabilityand a blameless culture, also known as a just culture. The residents perceived the stigma of medical error was decreased withoutquestioning the competency of the resident(s) involved. More frequent MandMCs, which were favored by all responding residents,should similarly promote a just culture that emphasizes patient safety through shared knowledge. By using our own missed cases asa tool to teach others, we acknowledge that errors will occur, and that these moments can serve as an opportunity for continuousiterative improvement in patient care.

Honored Educators


Ella A. Kazerooni, MD - 2014 Honored Educator

QS109-ED-MOB1

Decreasing Time to CT in ED Walk-in Stroke Patients: Using Lean Methods and MultidisciplinaryApproach to Meet the 25 Minute Guideline in a Joint Commission Certified Comprehensive StrokeCenter

Station #1

QSE-MOB

Quality Storyboards Monday Poster Discussions

Monday, Nov. 30 12:45PM - 1:15PM Location: QS Community, Learning Center


Participants

Sub-Events

AwardsIdentified for RadioGraphics

ParticipantsAleksandrs Kalnins, MD, MBA, Stanford, CA (Presenter) Nothing to DiscloseDaisha Marsh, ARRT, Stanford, CA (Abstract Co-Author) Nothing to DiscloseChristoph Zorich, Stanford, CA (Abstract Co-Author) Nothing to DiscloseWaimei Tai, Palo Alto, CA (Abstract Co-Author) Committee member, Boehringer Ingelheim GmbHNirali Vora, Stanford, CA (Abstract Co-Author) Nothing to DiscloseMary Brethour, PhD, Stanford, CA (Abstract Co-Author) Nothing to DiscloseStephanie Casal, MS, RN, Stanford, CA (Abstract Co-Author) Nothing to DiscloseGennette Olalia, RN, BSN, Stanford, CA (Abstract Co-Author) Nothing to DiscloseAkhila Pamula, MD, Stanford, CA (Abstract Co-Author) Nothing to DiscloseKandice Garcia, RN, MS, Stanford, CA (Abstract Co-Author) Nothing to DiscloseDavid B. Larson, MD, MBA, Los Altos, CA (Abstract Co-Author) Intellectual property license agreement, Bayer AG; Potentialroyalties, Bayer AGKevin H. Vantrees, MBA,ARRT, Stanford, CA (Abstract Co-Author) Nothing to DiscloseMax Wintermark, MD, Lausanne, Switzerland (Abstract Co-Author) Advisory Board, General Electric Company;

PURPOSE

To maintain stroke center certification, hospitals must meet guidelines defined by The Joint Commission (TJC) and the AmericanHeart Association/American Stroke Association (AHA/ASA). Qualifying stroke patients should receive tissue plasminogen activator(tPA) in less than 1 hour from emergency department (ED) door arrival time. The radiology department plays a critical role in theearly components of this process, including door to obtaining a noncontrast head CT scan within 25 minutes and door to CTinterpretation within 45 minutes. Acute stroke patients who walk into the ED without ambulance prenotification often do notreceive care within the mandatory timeframe. A multidisciplinary team used lean process improvement methods to address thesedelays. The project goal was to increase the percentage of ED walk-in stroke code patients who meet door to CT time within 25minutes in a Comprehensive Stroke Center to over 90% in a 5 month period.

METHODS

Members of Emergency Medicine, Neurology, Radiology and Radiology Quality Improvement departments formed a multidisciplinaryteam and learned lean process improvement through a guided curriculum (RITE: Radiology Improvement Team Education) over 5months (11/14 - 03/15). A3 project outlines were used to track results, focused on 7 components: Problem Statement,Background, Current State, Target State, Analysis, Key Drivers/Interventions and Sustain plan.Current state was defined by theteam through careful observation ("gemba") of ED stroke workflow among actual and mock stroke patients without ambulance pre-notification. At baseline, 12 steps consistently occurred in the stroke code workflow prior to a noncontrast head CT scan: a)patient triage, b) patient registration, c) stroke code activation, d) signing stroke order set, e) wristband placement, f) ED roomassignment, g) fingerstick glucose result, h) IV line placement, i) lab draw, j) patient weight, k) physical examination includingNational Institutes of Health Stroke Scale (NIHSS), and l) patient transport to CT.Root cause analysis of delays was illustrated in afishbone diagram organized by predefined categories: a) environment, b) materials, c) machines, d) people and e) methods. Sharedobservations and discussion at multidisciplinary team meetings defined key drivers in the process: a) rapid identification of strokecode, b) availability of timely, actionable, accessible data, c) well-defined roles/responsibilities, d) standardization of process priorto CT, e) ease of tracking process stages, f) improved access to materials and g) staff education of standardprocess.Interventions were developed to target each key driver. The first project intervention was to decrease the maximum stepsperformed prior to the initial CT study from 12 to 8 by allowing the patient to go immediately to the CT scanner without beingplaced in an ED room, and delaying the placement of an IV line, drawing labs, or completing NIHSS until after the noncontrast CT.The second project intervention was to integrate the preliminary intervention into a standardized ED triage process with clearlydefined roles and responsibilities for each participant in the stroke code.

RESULTS

Stroke coordinator records were used to calculate performance measures of door to CT time within 25 minutes among consecutivestroke code patients who walked into the emergency room before and after intervention. All cases were analyzed for drivers ofexcessive variability from the process. At baseline, 34% of 30 non-prenotified stroke code patients underwent noncontrast head CTin less than or equal to 25 minutes from ED door arrival, with a median time of 31 minutes. After the implementation of the first andsecond project interventions, 64% of 33 stroke code patients met the door to CT threshold of less than or equal to 25 minutes,with a median door to CT time of 19 minutes. 4 of the 33 cases demonstrated excess variability. In these cases, stroke codeactivation was delayed secondary to atypical initial patient presentation, with stroke symptoms only identified after initial triagehad taken place.

CONCLUSION

Using a team-based, multidisciplinary lean improvement process, door to CT time for walk-in ED stroke code patients improved 30%

QS111-ED-MOB2

Reduction of Outpatient Magnetic Resonance Imaging (MRI) Wait-time at a Hospital Setting

Station #2

in 5 months at our institution. The improvement process demonstrated that it is possible to reduce delays to CT by minimizing thenumber of steps performed prior to the acquisition of the initial noncontrast CT scan. The process variability above the desired 25minute threshold to CT emphasized the importance of effective early triage of walk-in ED patients and the need to promoteawareness of the new and truncated process. A mnemonic for the new process was created and displayed on visible billboards toremind of the new process steps. A working group was assembled to create an electronic dashboard with easily accessible real-timestroke code performance data to promote transparency and to support further process improvement efforts.

Honored Educators



ParticipantsShereef Ramadan, MD, San Diego, CA (Presenter) Nothing to DiscloseShazia Ashfaq, MBBS, MBA, San Diego, CA (Abstract Co-Author) Nothing to DiscloseNoushin Vahdat, MD, Cleveland, OH (Abstract Co-Author) Nothing to DiscloseFiona Cassidy, MD, San Diego, CA (Abstract Co-Author) Nothing to DiscloseLejla Aganovic, MD, La Jolla, CA (Abstract Co-Author) Nothing to DiscloseAmilcare Gentili, MD, San Diego, CA (Abstract Co-Author) Nothing to DiscloseAman Khurana, MD, San Diego, CA (Abstract Co-Author) Nothing to Disclose

PURPOSE

Long average wait time for performing outpatient MR Imaging studies at our hospital based Radiology department was addressed byassembling a multidisciplinary team in order to reduce the wait time through maximizing resources, waste elimination and processredesign. A Goal of accommodating 90% of the patients within 30 days of the desired date as entered by the clinical providers waschosen in order to improve timely access to medical care and to be compatible with the Institution goal.

METHODS

Multiple Plan Do Study Act (PDSA) cycles were performed. The project was initiated by data collection regarding theappropriateness of MRI studies based on McKesson Interqual criteria & American College of Radiology (ACR) criteria. Subsequently aRapid process improvement workshop (RPIW) was conducted through which quantitative and qualitative information collection tookplace through meetings with the core Radiology service stakeholders (Radiology Administrative director, Medical support assistants(MSAs) representative, MRI chief technologist, Radiology Service Chief, Clinical informatics research fellow and Chief RadiologyResident for quality and patient safety). Subsequent meetings and cooperation took place with the Chief of Primary care service,transport staff, PACS maintenance team and Radiology Residents to ensure a multi-source feedback with a patient centricapproach. Retrospective data was collected for annual MRI studies performed; including reviewing the basis for time allocation forMRI studies, average patient wait time and types of the most frequently requested MRI studies. Based on these metrics, theconceived process improvement strategies were implemented while noting subsequent effects on the average wait time per monthand percentage of the patients getting the MRI study performed in less than 30 days from the desired date as entered by theclinical provider per month. These two measures were considered outcome measures. The number of MRI studies performed permonth was considered a process measure. Radiology technologists' satisfaction survey was conducted before and afterimplementing changes and considered a balancing measure. Multiple interventions were attempted: the most successful of whichincluded reducing waste by shifting to a more efficient MRI technologists weekday shifts, which reduced unnecessary overlap oftechnologist work shifts during the afternoon hours and extended work hours through the evening without adding extra weekdayswork hours for the individual technologist and maximizing resources by adding 8AM to 4PM slots on Sunday for one of the twoavailable MRI machines. Other attempted interventions included furnishing multidisciplinary Care coordination agreements for lumbarspine and knee MRI studies in order to reduce unnecessary MRI requests regarding these frequently requested studies. A Radiologyresident was involved in furnishing these agreements as part of his quality improvement training during Radiology residency.Ongoingefforts to implement an effective electronic protocoling system are currently underway.

RESULTS

The number of requested MRI studies at the Hospital increased from 10,392 MRI studies in fiscal year 2012 to 11,880 MRI studies infiscal year 2014; a 14.3% increase while still utilizing the same two MRI machines. From the start of the project till present, theaverage patient wait time for scheduling an MRI was reduced from 22 days to 17 days; a 23% reduction and the percentage ofpatients getting the MRI studies performed in less than 30 days from the desired date has increased from 71% to 89.1%. Key areasrequiring intervention were ensuring appropriateness of MR exam request, partially paper based workflow for MR protocoling andscheduling, shortage of MSAs and MRI technologists, poor utilization of Electronic Medical Record (EMR) user interface forComputerized Radiology Order Entry (CROE) and poorly designed patient screening forms.

CONCLUSION

Patient wait time for MRI performance at our Hospital decreased through a systematic approach towards work process analysis,planning, implementing small changes and eliminating waste of vacant MRI appointment slots. The project highlights the value ofincluding technologists and support staff in planning and implementing quality improvement interventions and utilizing theorganizational resources of a system redesign department to produce significant improvement. Improvement was gradual and followup is required to ensure consistent results. Needed long term measures to improve efficiency include converting to an effectiveelectronic protocoling system, implementing Care coordination agreements in order to ensure appropriateness of studies andoversight tools to ensure compliance as well as retaining trained support staff.

QS113-ED-MOB3

Reducing Fluoroscopic Dose of Routine Musculoskeletal Joint Related Procedures

Station #3

QS115-ED-MOB4

Go with the Flow: Leveraging the Electronic Medical Record to Enhance Contrast Safety

Station #4

ParticipantsMital K. Patel, MD, Cleveland, OH (Presenter) Nothing to DisclosePranav Chitkara, MD, Cleveland, OH (Abstract Co-Author) Nothing to DiscloseVikram A. Kinni, MD, Cleveland, OH (Abstract Co-Author) Nothing to DiscloseRati Patel, MD, Cleveland, OH (Abstract Co-Author) Nothing to DiscloseRyan F. Fisher, PhD, Cleveland, OH (Abstract Co-Author) Nothing to DiscloseNaveen Subhas, MD, Cleveland, OH (Abstract Co-Author) Research Grant, Siemens AG

PURPOSE

Given the recent emphasis on reporting radiology exam radiation doses within dictations, an increasing number of radiologists arebecoming aware of dose variations between exams and across institutional sites. Staff and fellows in our institution'sMusculoskeletal Radiology Department have anecdotally witnessed fluoroscopic radiation dose discrepancies between sites duringcommon musculoskeletal (MSK) procedures. We operate two outpatient imaging sites with one site (Site A) consistentlydemonstrating higher dose rates relative to the other site (Site B). Both units were operating manufacture default low dosesettings. We aim to interrogate the etiology of this discrepancy and implement new protocols to correct this issue by working incollaboration with the physics department at our institution. Our goal is to reduce the fluoroscopic dose rate by approximately 33%from baseline (20 mGy/min). Total dose was not used as a primary endpoint to avoid procedural times as a confouding variable.

METHODS

During a 3 month period from July to October 2014, 237 consecutive MSK joint procedures performed at Site A (Siemens ArcadisVaric) were evaluated. In addition, a total of 626 consecutive MSK joint procedures performed at Site B (Philips BV Pulsera) wereevaluated as a gold standard. Although dose rate was our primary variable, procedural times were also examined as a surrogatemarker for image quality. We hypothesized if image quality was degraded to a significant level, procedural times would increase tocompensate.A new protocol for Site A was devised based on fluoroscopic dose rate discrepancy compared to Site B. Modificationsof the Site A unit included lowering the frame rate from 8 to 4 frames/second and reducing the target detector dose from standardto reduced. Additionally, we retrained x-ray technologists to utilize this particular protocol for all future joint procedures. Wesubsequently recorded 144 consecutive procedures at Site A post-implementation of the aforementioned parameters over a 3month period (October 2014 - January 2015). Fluoroscopic times and dose rates were again recorded.

RESULTS

Overall, pre- and post-intervention cases demonstrated an average dose rate of 35.3 mGy/min and 22.9 mGy/min, respectively atSite A. This corresponds to a reduction of 35%. Site B, which acted as our gold standard, demonstrated a dose rate of 5.0mGy/min during this period. We surmise the absence of arthroplasty cases and younger demographics at site B was partiallyresponsible for lower dose rates. Procedures were further subcategorized into therapeutic hip injections, therapeutic shoulderinjections, and joint aspirations which demonstrated average dose rate reductions of 31%, 56%, and 42% respectively. Allcombined cases at Site A demonstrated a 19% average reduction in time, confirming image quality was not degraded to a levelwhere diagnostic challenges arose.

CONCLUSION

We achieved our target goal of >33% overall dose rate reduction at Site A by decreasing the frame rate and target detector dose.Although Site A did not contain a proprietary dose feature available at Site B (ie, "¼ dose option"), we were able to with theassistance of our physics team achieve a more comparable dose. Further dose rate decreases are likely attainable as very minimalimage quality is required for common fluoroscopic joint injections/aspirations. Based on our findings, we highlight the importance ofradiologists playing an active role in changing baseline fluoroscopic hardware parameters to yield a lower dose rate.

ParticipantsTravis Browning, MD, Dallas, TX (Presenter) Advisory Board, Hewlett-Packard Company; Advisor, McKesson CorporationJulie G. Champine, MD, Dallas, TX (Abstract Co-Author) Nothing to DiscloseKristen Bishop, MD, Dallas, TX (Abstract Co-Author) Nothing to DiscloseJason W. Wachsmann, MD, Dallas, TX (Abstract Co-Author) Nothing to Disclose

PURPOSE

Intravenous iodinated contrast agents for computed tomography (CT) are widely prescribed but known to have potential sideeffects, including nephrotoxicity and allergic reactions. It is critical to be able to administer contrast safely to a large number ofpatients. The purpose of this ongoing project is to leverage the tools within the Electronic Medical Record (Epic Systems, Verona)to facilitate identification of patients at risk for such reactions at every step of the process from order entry to beginning theexam.

METHODS

The tools leveraged include groupers, Best Practice Alerts (BPA), order sets, information displays embedded within workflows,electronic exam protocoling, and navigators. Groupers are lists of specific elements that share certain characteristics allowing themto be managed as a group. A BPA is a system alert that fires when programmed triggers occur, typically resulting in a popup windowdisplay with information and recommended actions. Order sets are groupings of individual orders, grouped to facilitate placing setsof orders in a standardized manner. Navigators arrange and order specific steps and actions that need to occur during EMRworkflows.

RESULTS

Two groupers were created to facilitate contrast management: one for all differing iodinated contrast medication names (includinggeneric terms) and one grouper for all imaging exams that utilize iodinated contrast (contrast exam grouper). Three BPAs werecreated for ordering clinicians at the time of imaging order entry. The first fires if a contrast exam grouper order is placed in a

QS004-EB-MOB

Staffing to Workload: Finding the Perfect Balance in Radiology's Interventional Practice-WorkforceModel for High Quality Patient Care Delivery

Hardcopy Backboard

QS005-EB-MOB

Direct, In-Person Communication between Subspecialty Radiologists and Acute Care Surgeons Leadsto Significant Alterations in Clinical and Surgical Decision-Making

patient with an EMR recorded contrast allergy. This BPA displays the reaction and provides recommendations based on severityfrom non-true allergies (such as nausea) where no precautions are needed, to mild reactions such as hives with a link to theprophylaxis order set, to details on anaphylactoid reactions and requirement to discuss with the radiologist in order to proceed. Inthe last year, this allergy BPA fired 42-99 times per month and the prophylaxis order set was placed 9-21 times per month. At thetime of electronic protocoling, the radiologist can visualize patient allergies in the information display and confirm that theappropriate prophylaxis orders were placed. During the protocoling step, the radiologist can click a single button to remind theperforming technologist to confirm the patient completed the prophylaxis regimen correctly. The second BPA alerts the orderingprovider for patients on metformin when placing contrast exam orders. The BPA reminds of the need to hold metformin for 48 hoursafter the imaging exam and to confirm renal function status prior to restarting. It also fires if a new order for metformin is placedwithin 48 hours of such an imaging exam's completion. In the last year, this BPA fired 379- 461 times per month for patients onmetformin and 50-85 times per month for newly placed metformin orders. The third BPA for ordering providers alerts when placingcontrast exam orders on a patient with renal insufficiency. This reminder alerts to the concern of renal insufficiency for contrastadministration and provides a link to the standardized hydration order set for inpatients. The outpatient process is enhancedthrough the electronic exam protocoling step where the radiologist can leave the default option of initiating the hydration protocolwhich authorizes the nursing staff to use the corresponding order set. In the last year, this renal insufficiency BPA fired 141-210times per month on outpatients and 268-348 times per month on inpatients. In the last year, the inpatient hydration order set wasentered 37-56 times per month and the outpatient hydration order set was entered 80-198 times per month. Finally, a standardizedexam begin navigator was implemented for technologists. Steps include displays for patient's allergies and information entered bythe protocoling radiologist (including reminders about allergy prophylaxis medication). For CT exams, a question is included forwhether the technologist plans on administering IV contrast. A BPA was designed to fire for the technologist if they indicated IVcontrast was going to be given but the order was not in the contrast exam grouper. This highlights the conflict between plannedaction and type of exam, and requests the technologist reconfirm the order and protocol as a safety check. This newest BPA fired8 times in the first full month of operation.

CONCLUSION

Leveraging the tools and workflows within the EMR can facilitate identification and management of patients at risk from allergies ornephrotoxicity related to iodinated contrast. Embedding this at exam order entry, exam protocoling, and beginning the exam canproduce a multilayer system of safety.

ParticipantsCindy Lehnertz, Rochester, MN (Presenter) Nothing to DiscloseJoe Klunder, Rochester, MN (Abstract Co-Author) Nothing to DiscloseLaura Tibor, MBA, BEng, Rochester, MN (Abstract Co-Author) Nothing to DiscloseAndrew Stockland, Jacksonville, FL (Abstract Co-Author) Nothing to Disclose

PURPOSE

The purpose of this project was to ensure that the staffing levels in the Interventional Radiology practice maintained an appropriatelevel for the workload. Staffing can be challenging for the interventional lab and radiology technologists because they cover fourseparate work areas with a high amount of variability in case volumes. The team wanted to develop a plan to maintain theappropriate amount of staff to cover all areas adequately, accommodating for the slowest to busiest workloads.

METHODS

The team used the DMAIC processes throughout the staffing to workload initiative. In the define and measurement phase, the teamcalculated the productivity percentage and determined a realistic goal. The team established the productivity percentage by findingthe staff's total worked hours compared to the total paid hours. The initial findings showed the baseline productivity percentagewas only at 56%, revealing that the practice had an abundant amount of unproductive paid time. The team determined a realisticgoal was to ensure the average productivity percentage is 75% or greater for the lab and radiology technologists in Neuroradiology,Vascular, and Operating Room sites by September 1, 2014. In the analysis phase, the team determined the workload drivers to bethe number of physicians, cases scheduled, and add on cases. Total cases for the four practice areas that the lab andtechnologists cover ranged from 19 to 64 cases per day. This large discrepancy was due to the fact that 50 percent of theworkload is composed of unscheduled daily add-on cases which are an important variable to be factored into improvementprocesses. In the improve phase, the leadership team changed the practice to aggressively offer time off to staff during slowertimes. As rooms finished their work for the day, leadership allowed additional people time off with or without pay. The team alsodeveloped a method to forecast workload using a regression analysis. The forecast allowed leadership to permit extra staff time offbased on the daily volume prediction. Seasonal trends were also found to be valuable in time off requests, permitting additionalstaff off during slower seasons. Lastly, leadership utilized slower time periods to allow staff to work on projects including coding,auditing, data collection, and quality initiatives. A recently implemented data tracker aided in tracking the time worked on theseprojects which allow the team to keep accurate records of our total productive time worked, including non-patient productivetime.In the control phase, leadership continues to collect and track the productivity percentage every pay period. If theproductivity percentage is 85% or higher for a 2 month period, this would necessitate requesting additional FTE, implementing crosstraining efforts, or looking into possible staff schedule changes. Conversely, if the productivity percentage is below 70% for a 2month period, possible actions would include looking at staff schedule changes, offering additional scheduled time off in advance,and aggressively offering unpaid time off.

RESULTS

After implementing these new processes, the average productivity percentage was 76% from May 1st, 2014 to Jan 1st, 2015. Thisequates to a 20% improvement from our baseline measurement of only 56%.

CONCLUSION

Our department continues to practice these techniques and guidelines with the hopes of maintaining an average productivity of75%.

Hardcopy Backboard

ParticipantsElliot Dickerson, MD, Greenwood Village, CO (Presenter) Nothing to DiscloseHasan Alam, Ann Arbor, MI (Abstract Co-Author) Nothing to DiscloseRichard K. Brown, MD, Ann Arbor, MI (Abstract Co-Author) Nothing to DiscloseJadranka Stojanovska, MD, MS, Northville, MI (Abstract Co-Author) Nothing to DiscloseMatthew S. Davenport, MD, Cincinnati, OH (Abstract Co-Author) Book contract, Wolters Kluwer nv; Book contract, Reed Elsevier;

PURPOSE

Effective radiologist-to-referrer communication is critical for the translation of medical imaging data into clinical action. Finalizedradiology reports created with misleading or absent clinical data can lead to suboptimal interpretation, while text-based reportsmissing important or nuanced language can impair referrer understanding. The purpose of this quality improvement effort was todetermine whether direct in-person communication between an acute care surgical team and subspecialized radiologists can altersurgical decision-making.

METHODS

Institutional review board approval was waived for this HIPAA-compliant quality improvement initiative. This prospective longitudinalquality improvement effort was conducted from January 1, 2015 to March 31, 2015. Members of an on-call acute care surgery team(attending surgeon, chief surgical resident, surgical residents, surgical interns) at our institution reported at prescheduled times tothe abdominal radiology reading room between 8 am and 5 pm, and met with a subspecialty-trained abdominal radiologist with 4-years' experience and a subspecialty-trained nuclear medicine radiologist with 30-years' experience. During each meeting,approximately one hour was spent reviewing recent and pertinent imaging for admitted acute care surgery patients relative to anactive clinical problem for which medical and/or surgical decision-making was pending. The cases to be discussed were either 1)pre-identified by the surgical chief resident and electronically communicated to the abdominal radiologist at 6 am the same day, or2) brought to the meeting by the surgical team (e.g., emergent consultations). Every case was either admitted to the acute caresurgical service (e.g., trauma, emergency, burn, critical care) or was an active surgical consult. All reviewed radiology examinationshad already been assigned a final report. The radiologic findings and dictated impressions were reviewed in an interactive manner bythe abdominal radiologist, the surgical team, and the original dictating radiologist(s) if they happened to be present. At theconclusion of each patient review, the radiologist and the attending surgeon completed an 18-question electronic surveyinstrument designed to quantify the effect of this in-person meeting on the clinical impression and surgical decision-making.Concordant and discordant surgical, clinical, and radiologic findings were discussed and recorded. The primary outcome was theproportion of patients for whom clinical care was altered as a result of the in-person meeting.

RESULTS

Eighteen patients were reviewed for six attending surgeons. The index radiology examinations consisted of 17 CT studies of theabdomen and/or pelvis, and one magnetic resonance cholangiopancreatography (MRCP). The number of comparison studiesreviewed per patient ranged from 1-10, and included plain radiography, CT, MR, and fluoroscopy. There were four (22%) majordiscrepancies between the reviewing radiologists and the finalized reports. In nine instances (50%), the in-person meeting led to aself-reported change in the attending surgeon's impression of the patient's diagnosis. In nine instances (50%), medical and/orsurgical decision-making was altered as a direct result of the in-person communication; of these, eight of nine (89%) were acutechanges in management and one of nine (11%) was a non-acute change in management. In seven of 18 patients (39%), the in-person review resulted in a decision to pursue or avoid surgery when the alternative was originally intended. Examples included: a)prompting surgery in a patient with a recurrent small bowel obstruction and a fixed but mobile transition point related to metastaticbreast cancer, b) avoiding surgery in a patient with radiation-induced colonic strictures and superimposed infectious colitis, c)prompting surgery in a patient for whom a prospectively reported giant diverticulum was actually extraluminal stool, and d) changingthe operative approach based on the location of the transition point in a patient with a small bowel obstruction.

CONCLUSION

Targeted in-person collaboration between subspecialized radiologists and the acute care surgery team can lead to substantial andfrequent changes in patient management. This model-which has been adopted at many institutions for chronic diseases likemalignancy-adds value in the acute care setting where frequent critical-care decision-making is the norm. The primary mechanismappears to be promotion of a shared mental model that facilitates the exchange of complex information.

SPPH22A Anatomy for SRS/SBRT

SPPH22B Small Field Dosimetry and Uncertainty

SPPH22

Physics Symposium: Best of the SRS/SBRT AAPM Summer School

Monday, Nov. 30 1:30PM - 5:45PM Location: S102C

PH SQ


Participants

LEARNING OBJECTIVES

1) Identify critical anatomical features of major SRS/SBRT targets. 2) Learn techniques used in small field dosimetry and the orderof magnitude of treatment uncertainties. 3) Learn essential treatment planning techniques, especially with regards to repiratorymotion management. 4) Gain knowledge about treatment delivery devices for SRS/SBRT. 5) Understand resources and safetypractices for SRS/SBRT.

ABSTRACT

This session summarizes the highlights of the 2014 AAPM Summer School on SRS/SBRT. The first speaker will highlight criticalanatomical structures which physicists and treatment planners need to be aware of in SRS/SBRT. Contouring atlases specific toSRS/SBRT are discussed, e.g. the consensus guidelines published by the spine consortium. The second lecture focuses on thephysics of small field dosimetry, which is a special skill set within the field of clinical medical physics. The state-of-the artrecommendation on detector selection and measurement techniques will be discussed, including current recommendations on theuse of detector correction factors. The third speaker will summarize treatment planning approaches specific to classic SRS/SBRTtargets in the brain, lung, GI and GU regions. The appropriate use of respiratory management techniques for SBRT in lung, liver andpancreas requires the careful and considerate application of complex technology. Current society recommendations and peer-reviewed literature on accepted approaches to respiratory motion management will be summarized. In the last decade, theselection of treatment machines capable of delivering SRS/SBRT treatments with the required spatial and dosimetric accuracy hasincreased significantly. The speaker will discuss the major technical components of each delivery device, highlighting strength andweaknesses of each system as they apply to SRS/SBRT. SRS/SBRT delivers a high dose with steep dose gradients in 1-5 fractions,using complex technology with image guidance. Both the risk of error and the impact of errors is amplified under thesecircumstances. The last speaker of this session will discuss selected case reports of errors, including a root cause analysis. Currentsafety initiatives and recommendations for improved safety practices will be introduced. Resources to guide safe and effectiveimplementation of an SRS/SBRT program will be discussed and shared with the audience.

Sub-Events

ParticipantsJosh Y. Yamada, MD, New York, NY (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

View learning objectives under the main course title.

ParticipantsSonja Dieterich, PhD, Sacramento, CA, ([email protected]) (Presenter) Scientific Advisor, MGS Research, Inc

LEARNING OBJECTIVES

View learning objectives under the main course title.

ABSTRACT

This session summarizes the highlights of the 2014 AAPM Summer School on SRS/SBRT. The first speaker will highlight criticalanatomical structures which physicists and treatment planners need to be aware of in SRS/SBRT. Contouring atlases specific toSRS/SBRT are discussed, e.g. the consensus guidelines published by the spine consortium. The second lecture focuses on thephysics of small field dosimetry, which is a special skill set within the field of clinical medical physics. The state-of-the artrecommendation on detector selection and measurement techniques will be discussed, including current recommendations on theuse of detector correction factors. The third speaker will summarize treatment planning approaches specific to classic SRS/SBRTtargets in the brain, lung, GI and GU regions. The appropriate use of respiratory management techniques for SBRT in lung, liver andpancreas requires the careful and considerate application of complex technology. Current society recommendations and peer-reviewed literature on accepted approaches to respiratory motion management will be summarized. In the last decade, theselection of treatment machines capable of delivering SRS/SBRT treatments with the required spatial and dosimetric accuracy hasincreased significantly. The speaker will discuss the major technical components of each delivery device, highlighting strength andweaknesses of each system as they apply to SRS/SBRT. SRS/SBRT delivers a high dose with steep dose gradients in 1-5 fractions,using complex technology with image guidance. Both the risk of error and the impact of errors is amplified under thesecircumstances. The last speaker of this session will discuss selected case reports of errors, including a root cause analysis. Currentsafety initiatives and recommendations for improved safety practices will be introduced. Resources to guide safe and effectiveimplementation of an SRS/SBRT program will be discussed and shared with the audience.

Active Handout:Sonja Dieterich

http://abstract.rsna.org/uploads/2015/15001967/SPPH22B.pdf

Handout:Sonja Dieterich

SPPH22C Treatment Planning and Respiratory Motion Management for SBRT

SPPH22D SRS/SBRT Delivery Devices

SPPH22E Safety and Quality for SRS/SBRT

http://abstract.rsna.org/uploads/2015/15001967/Dieterich SRS Dosimetry for RSNA FINAL.pptx

ParticipantsKristi R. Hendrickson, PhD, Seattle, WA, ([email protected]) (Presenter) Nothing to Disclose

LEARNING OBJECTIVES


ParticipantsJames Gordon, PhD, Detroit, MI (Presenter) Departmental Research Grant, Varian Medical Systems, Inc; Departmental ResearchGrant, Koninklijke Philips NV

LEARNING OBJECTIVES


ParticipantsStanley H. Benedict, PhD, Sacramento, CA (Presenter) Nothing to Disclose

LEARNING OBJECTIVES


Active Handout:Stanley H Benedict

http://abstract.rsna.org/uploads/2015/15001972/SPPH22E.pdf

SSE02-01 Evolution of a Breast Screening Program: Indicators of Efficacy

Monday, Nov. 30 3:00PM - 3:10PM Location: E450A

SSE02-02 The Inevitable Proportion of Overdiagnosis in the Norwegian Breast Cancer Screening Program


SSE02

Breast Imaging (Screening Issues)


BR DM SQ

AMA PRA Category 1 Credit ™: 1.00ARRT Category A+ Credit: 1.00

ParticipantsPaula B. Gordon, MD, Vancouver, BC (Moderator) Stockholder, OncoGenex Pharmaceuticals, Inc ; Scientific Advisory Board, Hologic,Inc; Scientific Advisory Board, RealImagingEtta D. Pisano, MD, Charleston, SC (Moderator) Founder, NextRay, Inc CEO, NextRay, Inc Research Grant, Koning CorporationResearch Grant, Koninklijke Philips NV Research Grant, Zumatek, Inc Research Grant, FUJIFILM Holdings Corporation Equipmentsupport, Siemens AG Research Grant, Siemens AG Equipment support, Koninklijke Philips NV Research Grant, Koninklijke Philips NV

Sub-Events

ParticipantsSamantha L. Heller, MD, PhD, New York, NY (Abstract Co-Author) Nothing to DiscloseSam Dumonteil, MBBS, London, United Kingdom (Abstract Co-Author) Nothing to DiscloseSue Hudson, London, United Kingdom (Abstract Co-Author) Nothing to DiscloseLouise S. Wilkinson, MBBCh, FRCR, London, United Kingdom (Presenter) Nothing to Disclose

PURPOSE

The purpose of this study is to evaluate how changes in practice and technology have impacted upon indicators of programefficacy in a regional breast screening program, including cancer detection rates (CDR), invasive versus in situ disease detectionrates, repeat operation rates, and age adjusted mortality.


This retrospective audit adheres to local policy on confidentiality.: Breast screening database was interrogated from March 1995 toApril 2014. :Number of women screened, recall rates, short term follow-up rates, overall CDR, invasive cancers, in situ cancers,interval cancers, and repeat operation rates were identified and compared for early versus later years of the screening program.

RESULTS

834,201 women were invited for routine screening over the study period, and 587,648 (70%) attended with 5021 cancersdetected.: Over study period, national screening age range has broadened (50-70 vs. 50-64) and:many more women are screenedper year (39,506 vs. 23,934).: There has been an increase in CDR (0.97% vs. 0.83) with an increase in detection of in situ :disease(0.267% versus 0.167%) and a decrease in interval cancer rate (0.15% versus 0.20%).: There has also been a decrease in repeatoperation rate:(15.7% versus 21.7%).:: Finally, there has been a decrease in regional age adjusted mortality (16.81/100,0000 vs.26.95/100,000) (see Table 1).::

CONCLUSION

Over the time period of the screening program, multiple improved performance indicators are noted, including increased CDR,decreased interval cancer rate, and decreased repeat operation rate.: This is thought to be multifactorial, secondary totechnological and quality assurance factors, including core biopsy versus fine needle aspiration (FNA), adoption of bilateral wholebreast ultrasound/bilateral axillary ultrasound in the context of newly diagnosed cancer, use of digital mammography, and vacuumassisted excision versus surgical excision.: We also find an age-adjusted decrease in regional mortality from breast cancer, but it isdifficult to prove that this is related to screening alone.:


This study evaluates changing factors contributing to improvements in our breast screening program.: :Results put into questionnegative evaluations of breast screening's efficacy based only on studies from early days of practice.

ParticipantsSolveig S. Hofvind, Oslo, Norway (Presenter) Nothing to DiscloseMarta Roman, Oslo, Norway (Abstract Co-Author) Nothing to DiscloseRagnhild Falk, Oslo, Norway (Abstract Co-Author) Nothing to Disclose

PURPOSE

To estimate the number of overdiagnosed women, defined as those diagnosed with breast cancer and who die within the lead-timeperiod.


In this modeling cohort study, we used incidence- and death statistics available online and published estimates of lead-time.Postulated cohorts of screened and not screened women aged 50-51 were followed for a period corresponding to ten biennialscreening exams during 20 years, and further ten years, to age 78-79. The increase in breast cancer incidence due to screeningwas estimated based on lead-time. The proportion of women diagnosed with breast cancer who died within the lead-time period

SSE02-03 The False Negative Rate of Annual Screening Mammography at an American Academic InstitutionUsing Digital Technology


SSE02-04 Balancing the Benefits and Harms Among Women Targeted by the Norwegian Breast CancerScreening Program


was assessed based on the differences in the cumulative number of breast cancer diagnosed in the non-screened and screenedcohort.

RESULTS

The proportion of overdiagnosed women in screened compared to non-screened cohort was 1.8%. Sensitivity analyses usingvarious assumptions increased the estimates up to a maximum of 4%

CONCLUSION

The proportion of women with breast cancer diagnosed after participation in a screening program and who died within the estimatedlead-time period was less than 4%. This inevitable proportion of overdiagnosis, should be emphasized in the definition andcommunication of the issue.


Approximately 2% of women with breast cancer diagnosed in a screening program are estimated to die within the lead-time period.

ParticipantsHannah Perry, MD,MS, Boston, MA (Presenter) Nothing to DiscloseJordana Phillips, MD, Boston, MA (Abstract Co-Author) Nothing to DiscloseShambhavi Venkataraman, MD, Boston, MA (Abstract Co-Author) Nothing to DiscloseVandana M. Dialani, MD, Boston, MA (Abstract Co-Author) Nothing to DiscloseValerie J. Fein-Zachary, MD, Boston, MA (Abstract Co-Author) Nothing to DiscloseAlexander Brook, PhD, Boston, MA (Abstract Co-Author) Spouse, Research Grant, Guerbet SATejas S. Mehta, MD, MPH, Boston, MA (Abstract Co-Author) Nothing to Disclose

PURPOSE

The majority of published data on the Breast Imaging medical audit is not based on current American practice and includesprograms that screen biennially or used film-screen mammography (MG). Current practice data is needed as performance metricsbecome more transparent. We determine the false negative rate at an American academic institution that screens annually usingdigital MG, and evaluate the MG features of these cases.


Patients diagnosed with breast cancer (BC) between 1/1/12 and 9/30/12 with a negative MG within 15 months prior to diagnosis(index MG) were included. Those with index MGs from outside institutions were excluded.Index MGs were reviewed by three breastimagers in two phases (initially blinded followed by non-blinded) according to the European Guidelines for Quality Assurance in BCScreening and Diagnosis. MGs were classified as true negative (TN) if initially correctly interpreted as negative and included trueinterval cancers, MG occult cancer, or minimal signs. MGs were classified as false negative (FN) if initially incorrectly interpreteddue to reader or technical error and represented missed BC. Abnormalities were recorded as calcifications, mass/focal asymmetry,asymmetry, or distortion.

RESULTS

71 of 220 BC cases met inclusion criteria. Average age was 60.5 years (range 38.5 - 87.6, SD 10.4). 33/71 (46%) had fatty orscattered fibroglandular tissue and 38/71 (54%) were heterogeneous or extremely dense. There were 13/71 (18%) in situ and58/71 (82%) invasive cancers.57/71 (80%) were TN and 14/71 (20%) were FN (95% CI: 12-31%). Of the 57 TN, there were 33(58%) interval cancers, 3 (5%) MG occult cancers and 21 (37%) minimal signs. Of 21 minimal signs, 6 were calcifications, 9asymmetries, and 6 mass/focal asymmetry. Of the FN, all cases were due to reader error, with 5 calcifications, 2 asymmetries and 7mass/focal asymmetry. Imaging presentation of the index MG was not different between the TN and FN groups.

CONCLUSION

Our American academic institution annual digital screening mammogram (MG) program had a false negative (FN) rate of 20%,compared to 20-30% reported for film-screen or biennial MG. FN cases had no distinguishing MG features.


Our annual digital screening mammogram (MG) program had a false negative (FN) rate of 20%, compared to 20-30% reported forfilm-screen or biennial MG. FN cases had no distinguishing MG features.

ParticipantsSolveig S. Hofvind, Oslo, Norway (Presenter) Nothing to DiscloseMarta Roman, Oslo, Norway (Abstract Co-Author) Nothing to DiscloseSofie Sebuodegard, Oslo, Norway (Abstract Co-Author) Nothing to DiscloseRagnhild Falk, Oslo, Norway (Abstract Co-Author) Nothing to Disclose

PURPOSE

The balance between benefits and harms of mammographic screening is debated. Our purpose was to estimate a balance sheet ofbenefits and harms for the NBCSP.


Data from published studies using individual level data from the NBCSP were used to assess the reduction in breast cancer mortality

SSE02-05 Is One Prior Enough: Does Comparing with Multiple Prior Examinations Impact Recall Rates atScreening Mammography?


SSE02-06 Is it Necessary to Perform Standard (Implant-full) Views in Screening Mammography for Womenwith Breast Implants?


versus over-diagnosis. The program invites all Norwegian women aged 50-69 years to biennial mammographic screening. Themortality reduction in the studies varied from 36.8% to 43.0% among screened women, with an average estimate of 39.9%.Estimates of over-diagnosis ranged from 1.8% to 19.6%, with an estimated average of 10.7%. The cumulative risk of a falsepositive result was 15.9% for additional imaging and 4.1% for an invasive assessment. The benefit-detriment ratio was computedfor different scenarios of mortality reduction and over-diagnosis.

RESULTS

For every 10,000 women screened according to the invitations and followed until age 79 we estimated that 54-63 women are savedfrom breast cancer death, 11-126 are over-diagnosed, 1590 have a false positive result with non-invasive assessment and 410have a false positive result with invasive procedures. The benefit-harm ratio between mortality reduction and over-diagnosis was0.4, 0.8, and 5.7 under the less favorable, average and most favorable estimates, respectively.

CONCLUSION

Using average estimates showed that about one woman is saved from breast cancer death for each woman over-diagnosed. Theratio estimates varied substantially and should be interpreted with care before it is communicated to women targeted by thescreening program


Approximately one woman is estimated to be saved from breast cancer death for each woman over-diagnosed in the NorwegianBreast Cancer Screening Program, although estimates varied substantially.

ParticipantsJessica H. Hayward, MD, San Francisco, CA (Presenter) Nothing to DiscloseKimberly M. Ray, MD, San Francisco, CA (Abstract Co-Author) Nothing to DiscloseDorota J. Wisner, MD, PhD, San Francisco, CA (Abstract Co-Author) Nothing to DiscloseEdward A. Sickles, MD, San Francisco, CA (Abstract Co-Author) Nothing to DiscloseBonnie N. Joe, MD, PhD, San Francisco, CA (Abstract Co-Author) Nothing to Disclose

PURPOSE

To evaluate the impact of comparison with multiple prior mammograms on the screening mammography recall rate (RR) relative tocomparison with a single prior mammogram.


We performed a retrospective search of our institutional mammography database for screening mammograms performed at ourfacility between 6/14/2010 and 3/3/2015. This yielded a dataset of 46,317 consecutive screening mammograms performed in22,792 women. We collected data on patient age, dates of mammograms recorded as comparisons in the clinical report andrecommendations for recall. Generalized estimating equation logistic model was used to determine the relative odds of recall as afunction of the number of comparison exams without and with adjustment for age as a confounding variable.

RESULTS

A total of 3,845 screening mammograms were interpreted with no prior comparison mammograms, 5,749 exams were interpretedwith a single prior and 36,723 exams were interpreted with two or more priors. Screening recall rates for mammograms interpretedwith no priors, one prior and two or more priors were 16.6%, 7.8%, and 6.3%, respectively. The unadjusted odds ratio (OR) ofrecall for mammograms compared with multiple priors versus one prior was 0.789 (95% CI: 0.711, 0.877; p<0.0001). After adjustingfor patient age, the OR of recall for the multiple prior group relative to the single prior group was 0.864 (95% CI: 0.776, 0.962;p=0.0074).

CONCLUSION

Comparison with two or more prior mammograms resulted in a statistically significant 14% reduction in the screening mammographyrecall rate relative to comparison with a single prior.


Comparison with multiple prior mammograms is a more effective strategy for reducing the screening mammography recall rate thancomparison with a single prior.

ParticipantsGun Ha Kim, Seoul, Korea, Republic Of (Presenter) Nothing to DiscloseHak Hee Kim, MD, Seoul, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseJoo Hee Cha, MD, Seoul, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseHee Jung Shin, MD, Seoul, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseEun Young Chae, Seoul, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseWoo Jung Choi, MD, Seoul, Korea, Republic Of (Abstract Co-Author) Nothing to Disclose

PURPOSE

To investigate the necessity of standard (implant-full) views in screening mammography for women with breast implants.


1441 mammograms with 838 silicone and 603 saline breast implants performed between January 2009 and September 2014 were

1441 mammograms with 838 silicone and 603 saline breast implants performed between January 2009 and September 2014 wereevaluated by two radiologists in consensus. Of the 1441 mammograms, 1328 were screening mammograms. Implant ruptures andbreast cancer with regard to the incidence, detection rate by implant-displaced (ID) and implant-full (IF) views, mean age ofruptured implants, mean average glandular dose were assessed. Implant ruptures were confirmed by US, MRI or surgery and breastcancer were proven by pathology.

RESULTS

In 1328 screening mammograms, implant ruptures were found in 14 (14/1328, 1%); 12 were intracapsular and the remaining twowere extracapsular ruptures. Intracapsular ruptures were detected with indirect sign in 7 (7/12, 58.3%) on IF views and 1 (1/12,8.3%) on ID views. All extracapsular ruptures (2/2, 100%) were demonstrable on both views. Incidental detection of implantruptures on mammograms which could not be demonstrable on US or MRI was absent. The mean age of the ruptured implants was16 years (range, 6 - 30 years). Breast cancer were found in 3 (3/1328, 0.2%); two cases were found only on ID views and theother one was demonstrable on both views. The mean average glandular dose per breast was 3.42 mGy for IF views and 1.88 mGyfor ID views.

CONCLUSION

The diagnostic gain of IF views in screening of implant ruptures and breast cancer was low. The mean average glandular dose for IFviews was 1.8 times higher than for ID views. Considering clinical low impact and cumulative radiation, routine performance of IFviews for screening mammography need to be reconsidered.


The number of women with breast augmentation is increasing, but there are no widely accepted imaging guidelines. Routineperformance of IF views for screening mammography need to be reconsidered.

MSAS24A Safety of the Gadolinium Chelates

MSAS24B Performing MRI Exams on Patients with Implant Devices

MSAS24

Hot Topics in MR Safety (Sponsored by the Associated Sciences Consortium) (An Interactive Session)

Monday, Nov. 30 3:30PM - 5:00PM Location: S105AB

MR SQ


ParticipantsKendra Huber, RT, BS, Castle Rock, CO (Moderator) Nothing to DiscloseSteven P. DeColle, Edmonton, AB (Moderator) Nothing to Disclose

Sub-Events

ParticipantsVal M. Runge, MD, Bern, Switzerland (Presenter) Research Grant, Siemens AG

LEARNING OBJECTIVES

1) List the minor adverse reactions that occur with Gd chelate administration, and their incidence. 2) Describe the knowninteractions of the weaker chelates with laboratory tests. 3) Formulate a strategy for contrast use in renal failure patients,considering the impact of NSF. 4) Describe the phenomenon of dentate hyper intensity, and its link to the weaker chelates. 5)Critique the available agents in terms of overall safety.

ABSTRACT

The gadolinium based MR contrast agents (GBCAs) consist of transition metal Gd ions (Gd3+) bound very tightly by chelating agentsto form a stable complex (minimizing dissociation in vivo), mitigating the substantial natural toxicity of the free metal ion. MRcontrast media, specifically the gadolinium chelates, are in general very safe and lack the nephrotoxicity associated with IVadministration of the iodinated agents. Nausea, hives, and taste disturbance are the most frequent adverse reactions caused byGBCAs. All of the available GBCAs have the same incidence of these minor adverse reactions, which is substantially less than withthe iodinated agents. It should be noted, however, that life-threatening anaphylactoid reactions - although extremely rare - canoccur after IV injection of any contrast agent.The GBCAs can, however, be differentiated on the basis of chelate stability, withimportant implications for clinical use. Nephrogenic systemic fibrosis (NSF) is a serious late adverse reaction associated withexposure to GBCAs in patients with renal insufficiency. In this situation, release of free Gd3+ is more likely to occur due to theextended presence of GBCAs within the body. Due to the advent of NSF, administration of three agents (Omniscan, Optimark, andMagnevist) is now contraindicated in several clinical situations (by both the FDA and the EMA), including specifically chronic severekidney disease.In the last year, administration of multiple doses of Omniscan, in patients with normal renal function, has also beenshown to be associated with changes in the globus pallidus and dentate nucleus, raising further questions regarding this agent, theleast stable of the GBCAs. Use of only the most stable agents (the macrocyclics) is strongly recommended (Dotarem, Gadovist, andProHance), with marked preferential use of these agents in developed countries.

ParticipantsWilliam H. Faulkner JR, BS, RT, Ooltewah, TN (Presenter) Speakers Bureau, Bracco Group; Consultant, Bracco Group; Consultant,Medtronic, Inc ; Speaker, General Electric Company; Consultant, Metrasens Ltd; Consultant, Aspect Imaging; Speaker, Siemens AG;

LEARNING OBJECTIVES

1) List and define the 3 approved labels for implants and devices as it relates to MRI. 2) Name common safety issues as it relatesto B0, B1 and time-varying gradient magnetic fields. 3) Describe the benefit of using B1+rms vs. SAR as it relates to heating ofimplants and devices. 4) Describe how static field relates to heating of implants and devices.

ABSTRACT

When performing an MR exam on patients with implants and devices there are many factors to consider as it relates to safety. Onemust first first positively identify the device and then determine the MR labeling and thus the conditions of use. The static (B0)magnetic field can produce torque and translational forces on ferromagnetic objects. Additionally Lenz forces may be encounteredwith conductive metals. The time-varying gradient magnetic fields have been shown to adversely affect some types of activedevices. Radio frequency (B1) fields can result in significant heating and sever burns. It's important for those who are exposingpatients to these powerful magnetic fields understand their effects.

SPSC30

Controversy Session: Gadolinium Contrast Agents and Adverse Effects: Too Much Attention or Too Little?

Tuesday, Dec. 1 7:15AM - 8:15AM Location: E451A

GU MR SQ



ParticipantsHero K. Hussain, MD, Ann Arbor, MI (Moderator) Nothing to DiscloseEmanuel Kanal, MD, Pittsburgh, PA (Presenter) Consultant, Boston Scientific Corporation; Consultant, Medtronic, Inc; Consultant,St. Jude Medical, Inc; Consultant, Bayer AG; Investigator, Bracco Group; Royalties, Guerbet SA; Martin R. Prince, MD, PhD, New York, NY, ([email protected]) (Presenter) Patent agreement, General Electric Company;Patent agreement, Hitachi, Ltd; Patent agreement, Siemens AG; Patent agreement, Toshiba Corporation; Patent agreement,Koninklijke Philips NV; Patent agreement, Nemoto Kyorindo Co, Ltd; Patent agreement, Bayer AG; Patent agreement, LantheusMedical Imaging, Inc; Patent agreement, Bracco Group; Patent agreement, Medtronic, Inc; Patent agreement, Topspins, Inc;Stockholder, Topspins, IncRichard H. Cohan, MD, Ann Arbor, MI, ([email protected]) (Presenter) Consultant, General Electric Company; ; ; Matthew S. Davenport, MD, Cincinnati, OH, ([email protected]) (Presenter) Book contract, Wolters Kluwer nv; Bookcontract, Reed Elsevier;

LEARNING OBJECTIVES

1) To discuss associations of gadolinium based contrast agents (GBCA) and Nephrogenic Systemic Fibrosis (NSF). 2) To reviewrates and types of acute adverse reactions in patients receiving GBCA, and to place those in perspective with respect to the risk ofNSF. 3) To discuss several other potential safety factors about GBCA, and to compare and contrast incidence of new potentialsafety factors among the various CNS-approved GBCA. 4) To explain the current thinking regarding imaging patients with renalimpairment, and to define renal function thresholds that might be useful for operationalizing imaging in this patient population.

ABSTRACT

To review associations of gadolinium based contrast agents (GBCA) and Nephrogenic Systemic Fibrosis (NSF), and discuss currentpractice patterns that led to almost complete elimination of NSF. Speaker: Martin Prince.To review rates and types of acuteadverse reactions in patients receiving GBCA, discuss principles of premedication and treatment, and place the acute adversereaction rate in perspective with respect to the risk of NSF. Speaker: Richard Cohan. To list and integrate several other potentialsafety factors about GBCA, other than NSF and acute allergic type, into the clinical decision making process about whether or notto administer GBCA, and to compare and contrast incidence of new potential safety factors among the various CNS-approved GBCAavailable today. Speaker: Emanuel Kanal. To explain the current thinking regarding imaging patients with renal impairment, tohighlight the differences that exist between serum creatinine-based and eGFR-based screening, and to define the ranges of renalfunction thresholds for which caution might be advised to avoid potential harm that might result from the administration of iodinatedand gadolinium-based contrast media. Speaker: Matthew Davenport.

URL

MSQI31A ABMS: Why Practice Quality Improvement is an MOC Requirement

MSQI31B ACR Perspective: How ACR Supports PQI

MSQI31C ABR Perspective: New PQI Efforts

MSQI31

Quality Improvement Symposium: The Value of Practice Quality Improvement

Tuesday, Dec. 1 8:30AM - 10:00AM Location: S406B

SQ

AMA PRA Category 1 Credits ™: 1.50ARRT Category A+ Credit: 0

ParticipantsElla A. Kazerooni, MD, Ann Arbor, MI (Moderator) Nothing to Disclose

Sub-Events

ParticipantsLois Margaret Nora, MD, JD, MBA, Chicago, IL (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Explain the role of practice assessment and performance improvement in Board Programs of Maintenance of Certification. 2)Explain new standards of MOC and how boards are increasing relevance and decreaseing burden for practicing physicians doingpractice assessment and performance improvement. 3) Assess the role of professional self-regulation in the future of health systemchange.

ABSTRACT

ABMS Board Certification is a longstanding and important component of the medical profession's professional self-regulation. TheABMS Program for Maintenance of Certification MOC (ABMS MOC®) activities emphasize ongoing professional development andassessment that is aligned with other professional expectations and requirements within health care. The ABMS Program for MOCincorporates the six core competencies defined by ABMS and the Accreditation Council for Graduate Medical Education (ACGME)[(1) practice-based learning and improvement, (2) patient care and procedural skills, (3) systems-based practice, (4) medicalknowledge, (5) interpersonal and communication skills and (6) professionalism] within a four-part framework: Professionalism andProfessional Standing; Lifelong Learning and Self-Assessment; Assessment of Knowledge, Judgment, and Skills; and, Improvement inMedical Practice. While these elements are consistent across all Member Boards, each board tailors the expectations within eachelement to meet the particular specialties for which it provides certification. This presentation will explain some of the changes andinnovations that ABMS Member Boards are incorporating into their MOC Programs and particularly the element related toImprovement in Medical Practice.

ParticipantsBibb Allen JR, MD, Birmingham, AL (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Describe the mandate for higher value care and such as the federal Physician Quality Reporting System and the American Boardof Radiology Practice Quality Improvement as it relates to Maintenance of Certification. 2) Describe the process for development ofmetrics appropriate to radiology. 3) Examine ways their practices can participate in these programs using workflow tools andregistry reporting. 4) Examine how registry reporting can provide benchmarks and dashboards for continuing practice improvement.

ABSTRACT

In an article in the New England Journal of Medicine in March 2015, Health and Human Services Secretary Sylvia Burwell set newtargets for value-based payments in Medicare. She states their goal is that 85% of Medicare fee-for-service payments will be tiedto quality or value by 2016. Most likely this will be administered through the Medicare Physician Quality Reporting System (PQRS);however, has been difficult thus far for many radiology practices to achieve full participation in PQRS. Additionally, the AmericanBoard of Radiology requires documentation of Practice Improvement Project (PQI) for participation in Maintenance of Certification(PQI). In an effort to prepare radiologists to be successful in demonstrating higher value care and because we believe radiologistswill be more likely to participate if what we measure provides value to ourselves and our patients, the American College of Radiologyis working with CMS and the ABR to develop meaningful metrics for radiology to be used for quality reporting. Radiologists are alsoworking to develop tools to capture the information as part of our daily workflow either though PACS, dictation software or EHR.While the information could be used internally for process improvement, if metrics are standardized, we have an opportunity fornational registry reporting which offers not only opportunity for internal process improvement but also benchmarking, and since CMSnow allows reporting PQRS metrics through a Qualified Clinical Data Registry, by reporting through these registries practices andindividuals can qualify for PQRS and by using this reporting as a basis for ABR quality activities, physicians may seamlesslyparticipate in PQI for MOC. Finally, registry reporting allows data mining and supports socioeconomic research in radiology, so wecan learn where there are opportunities for further improvement in the car of our patients.

ParticipantsMilton J. Guiberteau, MD, Houston, TX, ([email protected]) (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1.) Explain the implications of the ABMS MOC 2015 Standards for tailoring the American Board of Radiology's (ABR) MOC programrequirements to the practice environments and culture of radiological professionals. 2) Articulate the rationale for changes in the

ABR MOC Program to alleviate duplication of effort and overall resource burden in complying with MOC program requirements. 3)Implement changes in diplomates' personal MOC compliance plans to meet the requirements of MOC employing new options. 4)Explain ABR efforts to explore additional improvements to promote diplomate satisfaction and sense of accomplishment in MOCparticipation in the future.

ABSTRACT

In the 2015 MOC Standards, ABMS has reiterated and expanded its acknowledgment that the fundamental structure of MOCintended for all ABMS Board MOC programs may be best implemented by creating options for compliance which recognize the uniquecultures and practice environments of each medical specialty represented by its 24 member Boards. In response, the AmericanBoard of Radiology has instituted changes in its MOC program to alleviate duplication of effort in meeting the requirements of itsMOC program by recognizing and giving credit for diplomate efforts already expended as part of their ordinary workday, especiallythose pertinent to Quality Improvement (MOC Part IV). By doing so, the ABR is delivering on its goal of reducing the time andresource burdens of meeting the requirements of MOC while increasing diplomate satisfaction and sense of accomplishment in MOCparticipation.

MSQI32A Project Design: Choosing the Topic and Team

MSQI32B Using Data to Drive Improvement

MSQI32C QI in Radiology, the Joint Commission Perspective

MSQI32

Quality Improvement Symposium: Designing and Running a Successful Practice Quality Improvement Effort

Tuesday, Dec. 1 10:30AM - 12:00PM Location: S406B

SQ


ParticipantsOlga R. Brook, MD, Boston, MA, ([email protected]) (Moderator) Nothing to Disclose

LEARNING OBJECTIVES

Attendees scoring 80% or higher on the SAM test may earn a Quality Essentials Certificate in the "Quality Improvement in YourPractice" domain.

Sub-Events

ParticipantsJames R. Duncan, MD, PhD, Saint Louis, MO (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) List improvement topics that will resonate with their teams and hospital leadership. 2) Develop operational measures that alignwith the intent of their improvement projects. 3) Identify the key attributes that lead to high performing teams. Attendees scoring80% or higher on the SAM test may earn a Quality Essentials Certificate in the "Quality Improvement in Your Practice" domain.

ABSTRACT

Quality improvement begins when we acknowledge that our current products or services are less than ideal. In 2001, the Instituteof Medicine found that our "health care delivery system does not provide consistent, high-quality medical call to all people ….Indeed, between the health care that we now have and the health care that we could have lies not just a gap, but a chasm."While progress has been made since 2001, numerous opportunities for improvement remain. This session will include strategies forchoosing improvement topics in radiology. It will also walk participants through the process of forming an improvement team,creating a project charter and developing quality/safety metrics.

ParticipantsOlga R. Brook, MD, Boston, MA (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Participants will be taught the critical difference between data used for research and data used for improvement. 2) Introduceparticipants to The Model for Improvement, an applied sciences methodology that is both easy to apply and shown to havemanifest utility at solving wicked problems. Attendees scoring 80% or higher on the SAM test may earn a Quality EssentialsCertificate in the "Quality Improvement in Your Practice" domain.

ABSTRACT

The applied sciences have flurished in every industry in the United States with the key exceptions of both heatlhcare andeducation. The pressing demands of the future 'value based economy' will require the American healthcare industry to adoptmordern improvement sciencs methdology. A great first step for leaders is to understand the key difference between researchmethodology and improvement methdology. Participants will be introduced to the popular improvement methdology 'The Model forImprovement'. The 'MFI' is a very pragmatic and effective way at testing change that results in real sustainable quality, financial,service or operational improvement.

ParticipantsDavid W. Baker, MD, MPH, Oakbrook Terrace, IL (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) To gain knowledge about Joint Commission standards for radiation safety. 2) To become familiar with the principles of The JointCommission's Robust Process Improvement® model for improving quality of care. 3) To understand the Targeted Solutions Tool®approach for identifying key drivers of quality and safety at an institution to target for quality improvement. Attendees scoring 80%or higher on the SAM test may earn a Quality Essentials Certificate in the "Quality Improvement in Your Practice" domain.

ABSTRACT

Advances in diagnostic imaging have greatly improved the quality of medical care. However, imaging has substantial risks and istherefore an important target for projects to improve quality and safety. This talk will review diagnostic radiation-related SentinelEvents reported to The Joint Commission, Joint Commission Standards to prevent patient safety events, and ongoing and plannedinitiatives to improve imaging safety. It will also discuss The Joint Commission's Robust Process Improvement® model for qualityimprovement projects and The Joint Commission's Center for Healthcare Transformation's step-by-step process to accuratelymeasure an organization's actual performance, identify their barriers to excellent performance, and direct them to proven solutions

that are customized to address their particular barriers.

Active Handout:David William Baker

http://abstract.rsna.org/uploads/2015/15003472/Active MSQI32C.pdf

SSG05-01 Automated Tube Voltage Adaptation in Combination with Advanced Modeled Iterative Reconstructionin Thoracoabdominal Oncological Follow-up Third-generation Dual-Source Computed Tomography:Effects on Image Quality and Radiation Dose

Tuesday, Dec. 1 10:30AM - 10:40AM Location: E352

SSG05-02 Assessment of Sinogram-affirmed Iterative Reconstruction Techniques for Reduced Dose AbdomenCT


SSG05

Gastrointestinal (CT Dose Reduction)

Tuesday, Dec. 1 10:30AM - 12:00PM Location: E352

CT GI SQ



ParticipantsWilliam P. Shuman, MD, Seattle, WA (Moderator) Research Grant, General Electric CompanyKathryn J. Fowler, MD, Chesterfield, MO (Moderator) Research support, Bracco GroupAchille Mileto, MD, Durham, NC (Moderator) Nothing to Disclose

Sub-Events

ParticipantsJan-Erik Scholtz, MD, Frankfurt, Germany (Presenter) Nothing to DiscloseMoritz H. Albrecht, MD, Frankfurt am Main, Germany (Abstract Co-Author) Nothing to DiscloseKristina Husers, Frankfurt, Germany (Abstract Co-Author) Nothing to DiscloseMartin Beeres, MD, Frankfurt Am Main, Germany (Abstract Co-Author) Nothing to DiscloseClaudia Frellesen, Frankfurt, Germany (Abstract Co-Author) Nothing to DiscloseJulian L. Wichmann, MD, Charleston, SC (Abstract Co-Author) Nothing to DiscloseThomas Lehnert, MD, Frankfurt Am Main, Germany (Abstract Co-Author) Nothing to DiscloseRalf W. Bauer, MD, Frankfurt, Germany (Abstract Co-Author) Research Consultant, Siemens AG Speakers Bureau, Siemens AGThomas J. Vogl, MD, PhD, Frankfurt, Germany (Abstract Co-Author) Nothing to Disclose

PURPOSE

To evaluate image quality and radiation exposure of portal-venous-phase thoracoabdominal third-generation 192-slice dual-sourcecomputed tomography (DSCT) with automated tube voltage adaptation (TVA) in combination with advanced modeled iterativereconstruction (ADMIRE).


Fifty-one patients underwent oncological portal-venous-phase thoracoabdominal follow-up CT twice within 7 months. The initialexamination was performed on second-generation 128-slice DSCT with a fixed tube voltage of 120 kV in combination with filteredback projection reconstruction (FBP). The second examination was performed on a third-generation 192-slice DSCT usingautomated TVA in combination with ADMIRE. Attenuation and image noise of liver, spleen, renal cortex, aorta, vena cava inferior,portal vein, psoas muscle and perinephric fat were measured. Signal-to-noise (SNR) and contrast-to-noise ratios (CNR) werecalculated. Radiation dose was assessed as size-specific dose estimates (SSDE). Subjective image quality was assessed by 2observers using five-point Likert scales. Interobserver agreement was calculated using intraclass correlation coefficients (ICC).

RESULTS

Automated TVA set tube voltage of follow-up CT to 90 kV (n=8), 100 kV (n=31), 110 kV (n=11), or 120 kV (n=1). Average SSDEwas decreased by 34.9% with 192-slice DSCT compared to 128-slice 120-kV DSCT (SSDE, 7.8±2.4 mGy vs. 12.1±3.2 mGy;p<0.001). Image noise was substantially lower, SNR and CNR were significantly increased with 192-slice DSCT compared to 128-slice DSCT (all p<0.005). Image quality was voted excellent for both acquisition techniques (5.00 vs. 4.93; p=0.083) withoutsignificant differences.

CONCLUSION

Automated TVA in combination with ADMIRE in third-generation 192-slice portal-venous-phase thoracoabdominal DSCT reducesaverage radiation dose by 34.9% compared to 128-slice DSCT while providing improved objective image quality.


Automated TVA in combination with ADMIRE is feasible in routine thoracoabdominal follow-up CT on a third-generation DSCT andresults in substantial dose reduction without impairment of image quality.

ParticipantsAtul Padole, MD, Boston, MA (Presenter) Nothing to DiscloseNisha Sainani, MD, Boston, MA (Abstract Co-Author) Nothing to DiscloseShelly Mishra, Boston, GA (Abstract Co-Author) Nothing to DiscloseAzadeh Tabari, Boston, MA (Abstract Co-Author) Nothing to DiscloseAlexi Otrakji, MD, Boston, MA (Abstract Co-Author) Nothing to DiscloseMannudeep K. Kalra, MD, Boston, MA (Abstract Co-Author) Nothing to DiscloseSubba R. Digumarthy, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose

SSG05-03 Contrast Enhanced CT Exams of the Abdomen Obtained at Low kVp: Impact on Radiation Dose andImage Quality


Venkatesh Arumugam Murugan, MBBS, Somerville, MA (Abstract Co-Author) Nothing to Disclose

PURPOSE

To assess the different settings of Sinogram-affirmed iterative reconstruction (Safire, Siemens Healthcare, Germany) techniques forreduced dose (RD) abdomen CT to the standard dose (SD) CT.


In an IRB approved prospective study, 20 patients (age 68 ± 6 years, M:F 11:9) undergoing SD abdominal CT on 128-MDCT(Definition Edge with Stellar detectors) scanner gave informed consent for acquisition of an additional RD CT. The RD series wereacquired with reduced tube current but identical scan length compared to the SD CT. The sinogram data of RD CT werereconstructed with three settings of Safire (S1, S3, S5) and SD CT reconstructed with Safire (S3) (n= 4*20=80 series).Radiologists performed independent, random, and blinded comparison for lesion detection, lesion conspicuity, and visibility abdominalstructures, first for all patients on RD dose images and subsequently for SD images.

RESULTS

Mean CTDIvol were 9±3 mGy and 1.4±0.1 mGy for SD CT and RD CT, respectively. There were total 70 lesions detected on SD CT.There were five missed lesions (4 liver lesions, 2-4 mm, and a liver mass < 1.2 cm) and a pseudo liver lesion (<4 mm) on RD imagesregardless of Safire settings and size of patients. The lesion conspicuity was sufficient for clinical diagnostic performance for 25/45lesions with RD S1, 27/45 lesions with RD S3, and 24/45 lesions with RD S5 images regardless of patient size. Visibility of normalliver and renal parenchyma was sufficient on 15/20 patients with RD S1, 16/20 patients with RD S3, and 9/20 patients with RD S5.Other abdominal structures such as adrenals, pancreas, gall bladder, and bowels were sufficiently seen in most patients on RD CT.

CONCLUSION

SubmSv radiation doses for routine abdominal CT are associated with missed lesions and suboptimal image quality despite use ofhigher strength iterative reconstruction techniques.


Abdominal CT acquired at CTDIvol of 1.4 mGy is not sufficient for diagnostic confidence.

Honored Educators


Subba R. Digumarthy, MD - 2013 Honored Educator

ParticipantsYasir Andrabi, MD, MPH, Boston, MA (Abstract Co-Author) Nothing to DiscloseRani S. Sewatkar, MBBS, Edison, NJ (Abstract Co-Author) Nothing to DiscloseManuel Patino, MD, Boston, MA (Abstract Co-Author) Nothing to DiscloseFarhad Mehrkhani, MD, Boston, MA (Abstract Co-Author) Nothing to DiscloseAndrea Prochowski Iamurri, MD, Boston, MA (Abstract Co-Author) Nothing to DiscloseSeyed Mahdi Abtahi, MD, Revere, MA (Abstract Co-Author) Nothing to DiscloseAvinash R. Kambadakone, MD, Boston, MA (Abstract Co-Author) Nothing to DiscloseDushyant V. Sahani, MD, Boston, MA (Presenter) Research Grant, General Electric Company; Research Consultant, AllenaPharmaceuticals, Inc

PURPOSE

Low tube potential (kVp) is increasingly being applied for contrast enhanced (CE) CT exams due to availability of software solutionsfor automated kVp selection on new generation scanners. Therefore, we studied the impact of low kVp imaging on the radiationdose and image quality of CE abdominal CT exams obtained on new generation scanners with automated kVp selection.


In this IRB approved retrospective study, 362 patients (age=55 years, weight=77.6 kg) underwent CE abdominal CT exams on oneof our 4 scanners from same vendor (Siemens) during one month period. All of these 4 CT scanners [Stellar Detectors=3 (DefinitionForce, Flash and Edge) and conventional Solid detector=1 (Force)]have automated kvp selection (80-140) option. Radiation doseinformation and applied scan parameters (kVp and mA) were retrieved. For 85 randomly sampled patients, contrast-to-noise ratio(CNR) was determined and subjective IQ assessment was done by 2 radiologists.

RESULTS

Low kVP (≤110 kVp ) was applied in 78%(281) CT exams [80 kVp=4(1%);90 kVp=22(6%);100kVp=251(70%); 110kVp=4(1%)] while22% of exams (n=81) were obtained at high kVp [120kVp=78(21%);140kVp=3(1%)]. The radiation doses showed a strongcorrelation with kVp [CTDI(mGy): 80=6.1;90=6.3;100=8.1;110=10.9; 120=14.1;140=22.9; r2=0.46,p<0.001]. For patients ≤91 kg,80% of exams were performed at low kVp corresponding to 49% lower radiation doses (mGy;≤110 kVp =6.5,120kVp=12.6;p<0.001).For >91kg, 69% of exams were obtained at low kVp (mGy;≤110 kVp =9.6,≥120kVp=17.2, 44% reduction; p<0.001). The CNRshowed a linear decrease with an increase in the kVp with highest values noted for exams obtained at low kVp (r2=0.18,p<0.001).All 85 exams received high subjective image quality ratings.

CONCLUSION

A substantial (78%) of abdominal CT exams are obtained at low kVp [80% (≤91 kg) and 69% (>91kg)]. Regardless of the patientbody weight, CT exams obtained on new generation scanners with automated kVp selection option results in a significant reduction

SSG05-04 Personalized Liver CT Examination Protocol Based on BMI: Combination of Optimized kVp andOptimized Iodine Injection Method


SSG05-05 Can 3rd Generation Dual-source CT Achieve 70kV-imaging for Routine Contrast-enhanced Body CT?


in radiation doses (44-49%) while preserving objective and subjective IQ.


The clinical benefits of low kVp imaging are well recognized,however, image quality concerns may limit its implimentation in clinicalpractice . The new generation scanners with automated kVp selection, stellar detectors as well as iterative reconstructionsfacilitate low kVp exams without degrading image quality, especially, in large sized patients.

Honored Educators


Dushyant V. Sahani, MD - 2012 Honored EducatorDushyant V. Sahani, MD - 2015 Honored Educator

ParticipantsJian Jiang, MD, Beijing, China (Presenter) Research Grant, General Electric CompanyXiaoying Wang, MD, Beijing, China (Abstract Co-Author) Nothing to DiscloseWei Li, Beijing, China (Abstract Co-Author) Nothing to DiscloseKe Wang, MD, Beijing, China (Abstract Co-Author) Nothing to DiscloseMengxi Jiang, Beijing, China (Abstract Co-Author) Research Grant, General Electric CompanyXiaochao Guo, MD, Beijing, China (Abstract Co-Author) Nothing to Disclose

PURPOSE

To investigate whether the personalized liver CT examination protocol based on body mass index (BMI) could obtain the diagnosticimage quality.


This prospective study was approved by IRB. Informed patient consent was obtained. From 2014 May to 2015 March, patients withknown or suspected HCC were recruited consecutively, who underwent MDCT. Patients were scanned with different tube voltage(80-120 kVp) in combination with different amount of iodine contrast medium (352 to 550 mgI/kg) based on their BMI: BMI 18.0-24.0, 80-kVp, 352mgI/kg; BMI 24.1-28.0, 100-kVp, 440 mgI/kg; BMI 28.1-35.0, 120-kVp, 550 mgI/kg. All the other scanningparameters were set as the same. For each patient, the late arterial phase images were reconstructed into 6 sets of images, filterback projection (FBP) and sonogram-affirmed iterative reconstruction (SAFIRE) 1 to 5 (S1 to S5). The image noise, attenuation,contrast-to-noise ratio (CNR), and figure of merit (FOM) of the liver parenchyma and portal vein and estimated effective dose (ED)were measured and calculated. Radiologists were independently blinded to grade images quality (sharpness, image noise, beam-hardening artifacts and reconstruction artifact).

RESULTS

Totally 133 patients were recruited, according to BMI, 37 in 80-kVp group, 50 in 100-kVp group, 47 in 120-kVp group. Imagesubjective score of S3 was significantly higher than that of the other reconstructions on the 80-kVp. Images of S2 had the highestimage subjective score compared with the other reconstructions on the 100-kVp (p<0.05) and 120-kVp (p>0.05). The estimated EDwas 49.6%, 56.8% lower at 80-kVp than at 100-kVp and 120-kVp. CNR of the portal vein was 16.3% higher at the 80-kVp S3images than of 120-kVp S2 images (p>0.05). FOM of liver on the 80-kVp S3 images was higher than on 100-kVp and 120-kVp S2images (p < 0.05). The subjective score of image quality was significantly higher for 120-kVp S2 images than for 80-kVp S3 imagesand 100-kVp S2 images; however, there was no significant difference among them.

CONCLUSION

High quality liver CT images could be obtained by using personalized liver CT protocol based on BMI, with combination of optimizedkVp and iodine injection method.


This method will be of benefit to the patients with lower BMI, who will receive lower contrast dosage, significantly less radiationdose compared with the conventional uniform method.

ParticipantsSatoru Takahashi, MD, Kobe, Japan (Presenter) Nothing to DiscloseNoriyuki Negi, RT, Kobe, Japan (Abstract Co-Author) Nothing to DiscloseKiyosumi Kagawa, Kobe, Japan (Abstract Co-Author) Nothing to DiscloseYoshiko Ueno, MD, Kobe, Japan (Abstract Co-Author) Nothing to DiscloseTatsuya Nishii, MD, PhD, Kobe, Japan (Abstract Co-Author) Nothing to DiscloseAtsushi K. Kono, MD, PhD, Kobe, Japan (Abstract Co-Author) Nothing to DiscloseWakiko Tani, RT, Kobe, Japan (Abstract Co-Author) Nothing to DiscloseHideaki Kawamitsu, MD, Kobe, Japan (Abstract Co-Author) Nothing to DiscloseKazuro Sugimura, MD, PhD, Kobe, Japan (Abstract Co-Author) Research Grant, Toshiba Corporation Research Grant, KoninklijkePhilips NV Research Grant, Bayer AG Research Grant, Eisai Co, Ltd Research Grant, DAIICHI SANKYO Group

PURPOSE

Low-kV CT can dramatically reduce contrast media (CM) volume with maintaining sufficient contrast enhancement thanks to

SSG05-06 Observer Performance at Varying Dose Levels and Reconstruction Methods for Detection of HepaticMetastases


Low-kV CT can dramatically reduce contrast media (CM) volume with maintaining sufficient contrast enhancement thanks toimproved iodine absorption of lower kV. Although low-kV CT has been applied to vascular imaging, its application to parenchymalorgans is limited due to high image noise or beam hardening artifact. The purpose of this investigation is to compare quantitativeand qualitative data in two contrast enhanced CT protocols acquired with 3rd generation dual-source CT scanner; 70 kV CT with60% dose of CM and 120 kV CT with a standard dose.


We retrospectively compared 100 consecutive patients (57±12 kg) who underwent post-contrast body CT (thorax to pelvis) on192-slice 3rd generation dual-source CT scanner at 70 kV with 60% dose of diluted 270 mgI/Kg CM (50.8±9.6 mL), with 103historical control patients (59±13 kg) at 120 kV with a standard dose of 450 mgI/Kg CM (84.4±16.4 mL). CT values of the vesselsand the visceral organs, as well as contrast to noise ratio (CNR) of hepatic and renal cysts were compared between the groups.Subjective assessment of image quality, severity of beam hardening artifact was scored on a 4-point scale. Radiation dose(CTDIvol) was recorded in each case.

RESULTS

CT values of the abdominal aorta, portal vein, liver, kidney, pancreas, spleen at 70 kV with 60% CM were statistically significantlygreater than those at 120 kV with a standard dose of CM (p<0.0001).There were no significant differences in CNR of hepatic orrenal cysts between 70 kV and 120 kV techniques (p=0.93, p=0.11, respectively). The beam-hardening artifact at the level ofthoracic inlet and the pelvis was stronger at 70 kV (120 kV, 1.1 and 1.0, 70 kV, 1.6 and 1.3, respectively), while streak artifactfrom intravenous CM was significantly more prominent at 120 kV technique (120 kV, 2.1, 70 kV, 1.5, respectively). Radiation dosewas significantly higher in the 120 kV than 70 kV group [CTDIvol; 9.1±1.7 mGy, and 8.3± 2.0 mGy, respectively (p<0.01)].

CONCLUSION

70kV-CT would be sufficient for routine clinical body CT study with reduced CM and radiation dose. Although beam hardeningartifact may be seen in the pelvis and the thoracic inlet, streak artifact from CM could be reduced.


70kV imaging can provide sufficient image quality not only for the vessels but also for the organs with reduced dose of CM andradiation.

ParticipantsJoel G. Fletcher, MD, Rochester, MN (Presenter) Grant, Siemens AG; ; Jeff L. Fidler, MD, Rochester, MN (Abstract Co-Author) Research Grant, Beekley CorporationSudhakar K. Venkatesh, MD, FRCR, Rochester, MN (Abstract Co-Author) Nothing to DiscloseDavid M. Hough, MD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseNaoki Takahashi, MD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseLifeng Yu, PhD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseMaria Shiung, Rochester, MN (Abstract Co-Author) Nothing to DiscloseAdam Bartley, Rochester, MN (Abstract Co-Author) Nothing to DiscloseShuai Leng, PhD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseDavid R. Holmes Iii, PhD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseAlicia Toledano, DSc, Washington, DC (Abstract Co-Author) President, Biostatistics Consulting, LLCRickey Carter, PhD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseCynthia H. McCollough, PhD, Rochester, MN (Abstract Co-Author) Research Grant, Siemens AG

PURPOSE

To estimate the ability of abdominal radiologists to detect hepatic metastases (HM) at varying dose levels with or without iterativereconstruction (sinogram-affirmed iterative reconstruction; IR) using a two-stage study design.


For stage I, CT projection data from 44 CT contrast-enhanced exams were collected (22 with HM). HM was defined byhistopathology, progression/regression on CT/MR. Using a validated noise insertion technique, 12 datasets were reconstructed withfiltered back projection (FBP) or IR for each patient at 6 dose levels (automatic exposure control settings of 60, 80, 100, 120, 160and 200 Quality ref. mAs [QRM]; 528 cases). In each reading session, 3 abdominal imagers randomly evaluated each patient'sdataset once. Using a dedicated computer workstation, readers circled all liver lesions, selecting diagnosis and confidence score (0- 100), and then graded image quality. Automated matching of reference and reader lesions was performed using overlappingspheres. A successful reading was defined as ≥ 2 readers localizing all "essential" HM (or no non-lesion localizations in negativecases), where an essential HM was identified by the reference standard and ≥ 2 readers at 200 QRM FBP. Sample size calculations(p0=0.8, p1=0.9, alpha=0.05 (one sided)) determined ≥ 37 cases to pass through stage I. JAFROC analysis was also performed on aper-lesion basis for HM using a non-inferiority limit of -0.1

RESULTS

There were 75 HM with a median size of 1.2 +/- 0.6 cm. 7 of the 12 configurations passed through stage I screening, correspondingto dose levels of ≥120 QRM (or at 100 QRM with IR). Using non-inferiority criterion and JAFROC FOM, all but the IR 60 QRM met thea priori definition of having the lower limit of 95% CI > -0.1. At dose levels ≤ 120 QRM, IR improved diagnostic confidence (p<0.05).

CONCLUSION

Lower dose CT images reconstructed at dose levels corresponding to 120 and 160 QRM, or at 100 QRM for IR only, performed similarto 200 QRM FBP in this pilot study for detection of hepatic metastases. IR improved diagnostic image quality but not performanceat lower dose levels.


Pilot data obtained over a range of doses suggests that substantial dose reduction is possible without compromising performance.

SSG05-07 Single- and Dual-Energy Acquisition with 2nd and 3rd Generation Abdominal Dual-Source CT: DirectComparison of Scan Modes Regarding Radiation Dose and Image Quality


SSG05-08 CT Enterography: Diagnostic Value Of 4th Generation Iterative Reconstrution Algorithm with LowDose CT-Protocol In Comparison with Standard Dose Protocol for Clinical Follow-Up of Patients withCrohn's Disease


Pilot data obtained over a range of doses suggests that substantial dose reduction is possible without compromising performance.IR improved performance only over a narrow range of radiation doses.

Honored Educators


Naoki Takahashi, MD - 2012 Honored Educator

ParticipantsJulian L. Wichmann, MD, Charleston, SC (Presenter) Nothing to DiscloseLloyd Felmly, Charleston, SC (Abstract Co-Author) Nothing to DiscloseCarlo N. De Cecco, MD,PhD, Charleston, SC (Abstract Co-Author) Nothing to DiscloseAndrew D. Hardie, MD, Charleston, SC (Abstract Co-Author) Nothing to DiscloseThomas J. Vogl, MD, PhD, Frankfurt, Germany (Abstract Co-Author) Nothing to DiscloseU. Joseph Schoepf, MD, Charleston, SC (Abstract Co-Author) Research Grant, Bracco Group; Research Grant, Bayer AG; ResearchGrant, General Electric Company; Research Grant, Siemens AG; Research support, Bayer AG; ; ; Akos Varga-Szemes, MD, PhD, Charleston, SC (Abstract Co-Author) Nothing to DiscloseStefanie Mangold, MD, Charleston, SC (Abstract Co-Author) Nothing to DiscloseGiuseppe Muscogiuri, MD, Charleston, SC (Abstract Co-Author) Nothing to DiscloseStephen R. Fuller, Charleston, SC (Abstract Co-Author) Nothing to DiscloseChristian Canstein, Charleston, SC (Abstract Co-Author) Employee, Siemens AG

PURPOSE

To compare dual-energy (DE) and single-energy (SE) abdominal computed tomography (CT) in matched cohorts of routine clinicalpatients performed with third-generation dual-source CT (DSCT) and to assess differences in radiation dose and image qualitycompared to second-generation DSCT.


This retrospective study was approved by the local institutional review board with a waiver of written informed consent. A total of200 patients divided into four groups of 50 patients matched by gender and body mass index underwent portal-venous-phaseabdominal DECT with standard scan protocols on second-generation DSCT (SE 120-kV, group A; DE 80/140-kV, group C) and third-generation (100-kV SE, group C; 90/150-kV DE, group D) DSCT. Radiation dose was normalized for a typical scan length of 40 cm.Dose-independent figure-of-merit (FOM) contrast-to-noise ratios (CNR) were calculated for various organs and vessels. Subjectiveoverall image quality and image artifacts and reader confidence were assessed by three observers using five-point scales. Resultswere compared with two-way analysis of variance and intra-class-correlation coefficients.

RESULTS

Effective dose normalized for 40-cm acquisition was lowest in groups D (5.3 ± 1.9 mSv) and C (6.2 ± 2.0 mSv, P =0.103),significantly lower (both P <0.0001) compared to groups A (8.8 ± 2.3 mSv) and B (9.7 ± 2.4 mSv). Dose-independent FOM CNRpeaked for liver, kidney, and portal vein measurements (all P ≤0.0285) in group D. Results for pancreas and aorta did not reachsignificance compared to group C (both P ≥0.0719), but did compared to groups A and B (all P ≤0.0077). Overall subjective imagequality and image artifacts and reader confidence were consistently rated as excellent in all groups (all ≥1.53 out of 5).

CONCLUSION

Both acquisition modes with third-generation abdominal DSCT result in significantly lower radiation dose compared to second-generation DSCT while maintaining image quality. Third-generation abdominal DE DSCT can be routinely performed without any dosepenalty compared to SE acquisition.


Third-generation DSCT is more dose-efficient than second-generation DSCT; the spectral imaging opportunities of DE acquisitioncan be utilized without radiation dose penalty.

ParticipantsSophie Lombardi, Vimercate, Italy (Presenter) Nothing to DiscloseDavide Ippolito, MD, Monza, Italy (Abstract Co-Author) Nothing to DiscloseAlessandra S. Casiraghi, Casatenovo, Italy (Abstract Co-Author) Nothing to DisclosePietro A. Bonaffini, MD, Monza, Italy (Abstract Co-Author) Nothing to DiscloseCammillo R. Talei Franzesi, Milan, Italy (Abstract Co-Author) Nothing to DiscloseSandro Sironi, MD, Monza, Italy (Abstract Co-Author) Nothing to Disclose

PURPOSE

To compare radiation dose, image quality and diagnostic performance of low dose CT-enterography protocol (256 MDCT scanner)combined with iterative reconstruction algorithm (iDose4), with standard dose CT-enterography in follow-up of patients with knownCrohn's disease.

SSG05-09 Comparison of Model-based Iterative Reconstruction, Adaptive Statistical Iterative Reconstructionand Filtered Back Projection for Detecting Hepatic Metastases on Submillisievert Low-Dose CT

Tuesday, Dec. 1 11:50AM - 12:00PM Location: E352


Fifty-one patients (32 male; mean BMI 24.9), with CD underwent low-dose CTE scan in a single venous phase on 256 MDCTscanner (iCT, Philips) with following parameters:120 kV, automated mAs dose modulation, slice thickness 2mm, with iDose4 iterativereconstruction algorithm. The same patients underwent a standard dose examination on 256-rows CT scan (120kV, 200-400mAs,depending on patient weight, slice thickness 2mm). Two radiologists, blinded to clinical and pathological findings, independentlyevaluated, in each scan, HU values in bowel wall and presence of CD activity features (mural thickening and enhancement pattern,mesenteric fat stranding, comb sign, lymphoadenomegaly and disease's complications). Image noise and diagnostic quality wereevaluated using a 4-point scale. Dose-length product (DLP) was calculated and data from both examinations were compared andstatistically analyzed.

RESULTS

Low-dose CTE protocol showed high diagnostic quality in assessment of Crohn's disease features (i.e. mural thickening andenhancement, halo sign, mesenteric fat stranding, lymphadenopathy), which were detected in 43/51 (82%) of our series. Total DLPand CTDI were significantly (p<0,001) lower for CTE studies with iDose (607 mGy*cm and 12 mGy) as compared to standard doseexaminations (891 mGy*cm and 19.13 mGy), allowing an overall dose reduction of 35%. The objective noise measurements wereslightly higher in iDose images (DS 12.9) than in standard dose studies (DS 10.37) but not statistically significant difference wasachieved (p=0,06).

CONCLUSION

Low dose CTE protocol combined with iDose4 reconstruction algorithm offers high quality images with lower radiation dose, being auseful tool in CD patients management, in regard of their young age and the frequent imaging follow-up required.


Low-dose CTE protocol combined with iDose4 algorithm allows a significant reduction of radiation dose, while providing anappropriate diagnostic image quality for the evaluation of CD manifestations.

ParticipantsJung Hee Son, MD, Busan, Korea, Republic Of (Presenter) Nothing to DiscloseSeung Ho Kim, MD, Busan, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseJung Hee Yoon, MD, Busan, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseYedaun Lee, MD, Busan, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseYun-Jung Lim, Seoul, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseSeon Jeong Kim, Seoul, Korea, Republic Of (Abstract Co-Author) Nothing to Disclose

PURPOSE

To compare the image quality and diagnostic performance of model-based iterative reconstruction (MBIR), adaptive statisticaliterative reconstruction (ASIR) and filtered back projection (FBP) on submillisievert low-dose CT (LDCT) for detecting hepaticmetastases in patients with gastrointestinal cancer.


From February 2014 to September 2014, 38 consecutive patients (mean age 63 years; range 33-87 years) having clinicallysuspected hepatic metastases underwent abdomen CT. CT protocol consisted of routine standard-dose portal venous phase scan(120 kVp), and investigational 90 second delayed low-dose scan (80 kVp) with an automatic tube current modulation. The LDCTimages were reconstructed with FBP, ASIR 70% and MBIR. Two blinded readers independently scored overall image quality of eachimage set based on a five-point scale and recorded number of hepatic metastases on a per lesion basis (FBP, ASIR, and MBIR inorder). The subjective image quality was compared by Wilcoxon signed rank test. The CT image noise was measured for each imagedata set. The image noise and number of detected hepatic metastases were compared among the three image data sets using therepeated measures analysis of variance.

RESULTS

105 metastatic lesions (42 lesions ≥ 1 cm, 63 lesions < 1 cm) were analyzed. The mean values of CTDIvol and DLP of LDCT were1.66 mGy and 47.8 mGycm, respectively. The subjective image quality was improved in reading order for both readers (P<0.0001).The measured image noise was also decreased in reading order (40.5, 24.6, 14.8; P<0.0001). The pooled sensitivity was unchangedafter applying ASIR from 49% (51/105) to 52% (55/105) (P=0.0697), however, significantly increased to 66% (69/105) afterapplying MBIR for reader 1 (P=0.0035). MBIR applied images showed a higher pooled sensitivity than ASIR applied ones (P=0.0311).For reader 2, it was not increased after applying either ASIR from 65% (67/105) to 68% (70/105), or MBIR to 67% (69/105)(P=0.4571).

CONCLUSION

Although MBIR and ASIR might improve the subjective image quality and decrease measured image noise, the reconstructed imagesshowed a limited sensitivity in detecting hepatic metastases on submillisievert LDCT.


The MBIR or ASIR applied images show a limited sensitivity in detecting hepatic metastases on submillisievert LDCT.

SSG15-01 Shielding Gamma-rays from Nuclear Medicine Rooms: Monte Carlo Simulations of Ceiling Scatter inthe Diagnostic and Therapeutic Use of Tc-99m, I-131 and F-18

Tuesday, Dec. 1 10:30AM - 10:40AM Location: S404AB

SSG15-02 Radiation Dose Reduction using Added Beam-shaping Filtration in Lung-Cancer Screening CT


SSG15

Physics (Radiation Dose Control I)

Tuesday, Dec. 1 10:30AM - 12:00PM Location: S404AB

CT PH SQ


ParticipantsIoannis Sechopoulos, PhD, Atlanta, GA (Moderator) Consultant, FUJIFILM Holdings Corporation; Research agreement, Hologic, Inc;Research agreement, Barco nvXiujiang J. Rong, PhD, Houston, TX (Moderator) Nothing to Disclose

Sub-Events

ParticipantsRoald S. Schnerr, PhD, Maastricht, Netherlands (Presenter) Research Grant, Bayer AGAnouk de Jong, MSc, Breda, Netherlands (Abstract Co-Author) Nothing to DiscloseCecile R. Jeukens, PhD, Utrecht, Netherlands (Abstract Co-Author) Nothing to DiscloseGuillaume Landry, Garching, Germany (Abstract Co-Author) Nothing to DiscloseRoel Wierts, Maastricht, Netherlands (Abstract Co-Author) Nothing to Disclose

PURPOSE

In the design of diagnostic and therapeutic treatment rooms for Nuclear Medicine, an important consideration is the shieldingrequired for blocking the ionizing radiation from the radioactive isotopes. The primary radiation, possibly with build-up correction,can be calculated analytically. However, little data is available to estimate the radiation dose contribution of ionizing radiation thattravels over the (typically lead) shielding in the wall and scatters of the ceiling; so-called skyshine. We aim to determine thecontribution of this skyshine to the radiation dose received by people outside Nuclear Medicine rooms.


Monte-Carlo simulations were performed with Gate/Géant for different heights of lead shielding in the wall, and different ceilingheights. A point source of Tc-99m (141keV),I-131 (365keV) or F-18 (511keV) was placed free in air, 1m above the floor, 3m fromthe wall. We used lead shielding of 2mm (Tc-99m) and 8mm (I-131, F-18). In total 165 simulations were run; for each isotope wevaried the shielding height (between 1.8m and 5.0m) and ceiling height (3.0-5.0m). These simulations allow us to compare thecontribution of the direct radiation (through the shielding), and skyshine (over the shielding).

RESULTS

We find that the skyshine contribution to the total radiation dose varies greatly (from <2% to ~100%), and strongly depends onphoton energy. For low photon energies (e.g. Tc-99m) skyshine is often a dominant factor. For higher photon energies (e.g. F-18),shielding the primary radiation is typically the most important concern.

CONCLUSION

We have performed simulations that allow an estimation of the contribution of skyshine to the radiation dose outside a room, basedon room use (occupancy, total radioactivity used), ceiling- and shielding height and the isotope used. For lower photon energies(e.g. Tc-99m) this can be a major contribution, which, if neglected, can result in insufficiently shielded rooms. These results willallow for safer and better optimized shielding designs in Nuclear Medicine departments.


Our research will aid safer and better optimized shielding designs in Nuclear Medicine departments as the contribution of scatteredradiation from the ceiling (skyshine) can be properly accounted for.

ParticipantsChi Ma, PhD, Rochester, MN (Presenter) Nothing to DiscloseLifeng Yu, PhD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseShuai Leng, PhD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseCynthia H. McCollough, PhD, Rochester, MN (Abstract Co-Author) Research Grant, Siemens AG

PURPOSE

Added beam-shaping filtration such as the use of a tin filter may improve the dose efficiency of an x-ray beam by removing some ofthe low-energy photons that do not contribute to image quality. The purpose of this study was to evaluate the radiation dosereduction potential of a 100 kV beam with an added tin filter for different patient sizes.


An anthropomorphic chest phantom (Lungman, Kyoto Kagaku) with 2 additional attenuation layers was used to simulate small (35 x20 cm), medium (40 x 26 cm), and large (47 x 31 cm) adult patients. These phantoms were scanned on a 192-slice CT scanner(Force, Siemens) at 100 and 120 kV without tin filtration, and 100 and 150 kV with tin filtration (100Sn and 150Sn), each at 5

SSG15-03 Radiation Dose Reduction Using Mini-Mobile Digital Imaging System in a Neonatal Intensive Care Unit


SSG15-04 A Method for Dose Reduction in Dedicated Breast CT Using a Wedge Filter: Theory and PreliminaryValidation


different dose levels. The CTDIvol at each kV was matched to that in the 100Sn scan with quality reference mAs (QRM) values of300, 150, 100, 50, and 25. Images were reconstructed using an iterative reconstruction method (ADMIRE, Siemens) with a kernel ofBv49-2. A 0.6 cc point ion chamber was used to measure radiation dose at 6 locations of each phantom. For each phantom size,dose level, and kV setting, image noise at uniform areas of the central region was measured and averaged across 10 slices. Theaverage dose from the point-chamber measurement, instead of CTDIvol, was used to evaluate the dose efficiency. Radiation dosewas calculated for each kV and each phantom size such that the noise was matched to that in the 120 kV images acquired at adose level specified by 100Sn and 100 QRM, which was deemed clinically acceptable for lung cancer screening. The percent dosereduction of 100Sn relative to 120 kV for each phantom size was estimated.

RESULTS

100Sn generated images with the lowest noise among all tube voltages for all three phantom sizes at the same radiation dose. At adose level that is considered clinically acceptable (100Sn, 100 QRM), the noise was reduced by 31%, 30%, and 28% for small,medium, and large phantom sizes compared with 120 kV. The corresponding dose reduction was 52%, 51%, and 49%.

CONCLUSION

The 100 kV with an added beam filtration can reduce radiation dose by 49-52% compared with the 120 kV in lung cancer screeningCT.


Added beam filtration such as tin filter has the potential to improve dose efficiency in lung cancer screening CT.

ParticipantsYoogi Cha, Jeonrabukdo Iksan, Korea, Republic Of (Presenter) Nothing to DiscloseTaeyeong Heo, Iksan, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseDong Woon Heo, Iksan-City, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseJong Hyun Ryu, Iksan, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseChang Won Jeong, Iksan, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseTae-Hoon Kim, Iksan, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseHong Young Jun, PhD, Iksan, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseKyong Woo Kim, PhD, Jeonju, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseKwon-Ha Yoon, MD, PhD, Iksan, Korea, Republic Of (Abstract Co-Author) Nothing to Disclose

PURPOSE

The aim of this work was to determine the radiation dose received by infants from radiographic exposure and compare to mini-mobile digital imaging system (mini-DI) and conventional mobile digital radiography (DR) for entrance surface dose (ESD) and imagequality for neonatal chest imaging


The sample consisted of 20 neonatal chest x-rays of 12 neonates admitted and treated in a neonatal intensive care unit (NICU). Allthe neonates were preterm in the range of 25-35 weeks, with a mean of 31.5 weeks. We used a mini-DI system (Meteor,Nanofocusray Co. Ltd, Korea), which was adapted a flat-panel detector and monoblock X-ray source and conventional mobile DR(EFX vision, Shimadzu medical system, Japan) for comparison. The protocols of neonatal chest imaging were 60kV and 0.15 mAs formin-DI, and 60kV and 1.2 mAs for mobile DR, respectively. With each protocol and system, ESD was measured using a dosimeter(Piranha, RTI electronics, Sweden). Signal to noise ratio (SNR), contrast to noise ratio (CNR) and modulation transferring function(MTF,10%) were calculated for image quality using bar phantom (x-ray test pattern type 18, FUNK, Germany).

RESULTS

The mean ESD for the mini-DI and mobile DR were 28.3±0.09 μGy and 254.6±1.04 μGy, respectively (p< 0.001). Regarding imagequality, the mean SNR values for the mini-DI and mobile DR were 626.8 vs 18.4, the CNR value were 30.2 vs 26.8, and 10% MTFwere 131μm vs 162μm, respectively. The diagnostic performance of mini-DI was better than those of conventional DR.

CONCLUSION

The results of our study show that neonates received ten-times lower dose from mini-mobile digital imaging system compare toconventional mobile DR. The mini-DI would be useful with dose reduction and good image quality in a NICU considering thesensitivity of the neonates to radiation


The mini-mobile digital imaging system would be useful in a NICU for dose reduction considering the sensitivity of the neonates toradiation.

ParticipantsAndrew Hernandez, Sacramento, CA (Presenter) Nothing to DisclosePeymon Gazi, MS, Sacramento, CA (Abstract Co-Author) Nothing to DiscloseJohn M. Boone, PhD, Sacramento, CA (Abstract Co-Author) Research Grant, Siemens AG Research Grant, Hologic, Inc Consultant,Varian Medical Systems, Inc

PURPOSE

To improve image quality and reduce patient dose in dedicated breast CT (bCT) by means of a wedge filter design that modulates

SSG15-05 Five Year Review of Size and Age Specific CT Radiation Exposures in a Research Hospital DuringAdvanced Dose Reduction Initives


the x-ray beam in the cone angle direction.


Using a large cohort of breast CT images and the known geometry of our prototype bCT scanner, the x-ray path length profilethrough each breast as a function of position along the z-axis was obtained by ray tracing from the x-ray tube focal spot throughthe breast CT data and onto the detector panel, with some assumptions. A complete description of the air kerma at scannerisocenter and resulting arbitrary detector units (ADUs) on the projection images were then measured on our system by sweepingthrough all possible tube current values (up to detector saturation). Our bCT system's modeled x-ray spectra were thenmathematically filtered with increasing thicknesses of 20% glandular breast tissue to provide a relationship between changes in airkerma and hence ADU values with varying x-ray path lengths through breast tissue. For several different filter materials (Cu, Ti, andAl) a nonlinear regression algorithm was developed to estimate the wedge filter thickness profiles needed to equalize the ADUvalues (behind the breast) along the z-axis of the detector.

RESULTS

Using a 60 kV x-ray spectrum with 0.3 mm Cu pre-filtration, the wedge filter thickness profiles resulting from the proposed algorithmwere fit using linear regression and resulted in R² values > 0.9110 for all materials analyzed (Cu, Ti, and Al). The resulting wedge-shaped filters increased linearly from 0 mm (posterior edge of detector) to 1.1, 4.3, and 25.1 mm thick (anterior edge of detector)for the Cu, Ti, and Al filter materials, respectively.

CONCLUSION

A proposed design of a wedge-shaped filter for dedicated bCT has the potential of reducing patient dose by reducing incident airkerma along the thinner anterior regions of the breast where the dose is the highest; and improving image quality by reducing beamattenuation along the thicker posterior regions of the breast where image noise dominates. Furthermore, the proposed design isrobust because it makes use of a large number of patient bCT datasets and it would be relatively straightforward to implement onour prototype bCT systems.


This study is directly related to the improvement of clinical breast imaging because it has the potential of reducing patient dose andimproving image quality

ParticipantsLes R. Folio, DO, MPH, Bethesda, MD (Presenter) Research agreement, Carestream Health, IncWilliam Kovacs, Bethesda, MD (Abstract Co-Author) Nothing to DiscloseJianhua Yao, PhD, Bethesda, MD (Abstract Co-Author) Royalties, iCAD, IncDavid A. Bluemke, MD, PhD, Bethesda, MD (Abstract Co-Author) Research support, Siemens AG

PURPOSE

To review size and age specific CT exposures during various dose reduction initiatives over five years at a major research center.Our aim was to extract all CT exam exposure, size, age and other data from PACS dating back to 2010. Detailed data extractionsallow us to compare across research protocols and ordering physicians demonstrating successful targeted radiation exposurereductions relative to prior and new benchmark exposures. Principal Investigators establishing new research protocols use this datato select optimal scanner settings and dose reductions for their studies.


Using an in house extraction tool (Radiation Exposure Extraction Engine), we extracted CT exposure data from DICOM headers overthree (as of submission) years (Feb 2012 to March 2015). Parameters included age, anatomic region(s), phases, scan protocolsettings, research protocol number and ordering provider. We were also able to obtain body volume segmentation of scannedregions automatically with our extraction tool for accurate size estimation. Dose reduction initiatives included BMI based kVpreduction in 2010, model based iterative reconstruction starting in 2011, kVp modulation and application of Virtual non-contrast in2013. We compared dose reductions in our most common exams, including chest, abdomen and pelvis routine and triple phaseexams and chest CT.

RESULTS

As of submission, we have successfully extracted exposure data of 38,200 CT exams from eight scanners. We compared age andsize specific similar research protocols throughout the last three years with aggressive dose reduction initiatives on 554 researchprotocols and 87 CT scan protocols. Example CT exams presented showed significant dose reductions over each year (p < 0.001).

CONCLUSION

Collecting size specific CT exposure and other data over several years has allowed us to confirm and compare many types of dosereduction initiatives across several hundred research and scan protocols.We demonstrated significant dose reductions over eachyear of continued dose reductions on our most common exams.


Our results demonstrated and compared several successful exposure reduction initiatives during a dynamic time of advancedexposure reduction innovation.This is the largest review of CT exposures available to our knowledge that include parameters suchas age, body size, ordering doctor, research protocol number, etc.

SSG15-06 Virtual Non-enhanced Images Acquired by Material Suppression Iodine (MSI) in Enhanced SpectralCT Imaging on Chest: In Comparison with Plain Scan


SSG15-07 Quantifying Uncertainties in Absorbed Organ Dose Calculations in Monte Carlo Simulations of DentalCone Beam CT Applications


ParticipantsQimeng Quan, MD, PhD, Shanghai, China (Presenter) Nothing to DiscloseYuanjiong Chen, Shanghai, China (Abstract Co-Author) Nothing to DiscloseNianyun Li, Shanghai, China (Abstract Co-Author) Nothing to DiscloseNa Gao, Beijing, China (Abstract Co-Author) Nothing to DiscloseGui-Xiang Zhang, MD, Shanghai, China (Abstract Co-Author) Nothing to Disclose

PURPOSE

To evaluate the feasibility of virtual non-enhanced images post-processed by MSI in enhanced spectral CT imaging in comparisonwith the images of plain scan on chest.


The chest plain and iodine-enhanced standardized CT scanning was performed sequentially on 11 patients using a 64-row CTscanner (GE healthcare, Discovery CT750 HD). The enhanced images were post-processed into virtual non-enhanced imagesfollowing the function of material suppression iodine (MSI) on AW4.6 workstation (GE healthcare). The virtual non-enhanced imageswere compared with the images of plain scan by analyzing the CT values in selected vessels. The statistical analysis was carriedon.

RESULTS

The CT values of the region of interest (ROI) in thoracic aorta, ascending aorta, pulmonary artery trunk, and dorsal muscle inenhanced images of chest were 258.38±29.21HU, 266.37±36.02HU, 239.91±57.63HU, and 45.64±8.64HU. All CT values on MSIimages for the vessels mentioned above dropped to 44.00±6.23HU, 43.71±9.41HU, 47.03±11.93HU, 43.47±7.81HU, respectively.The MSI images demonstrated similar CT values as plain scan (40.25±6.19HU, 39.14±9.27HU, 40.11±11.01HU,and 50.41±9.96HU,respectively) (P>0.05). There were no significantly different values of CTDIvol between plain scan and enhanced CT scan(8.38±2.77 mGy vs. 8.85±1.83 mGy) (p>0.05) meanwhile.

CONCLUSION

Virtual non-enhanced images acquired by MSI effectively suppressed iodinate contrast, which was comparable to plain CT imageson chest. Successful substitution scans lead to nearly 50% radiation dose reduction and got equal image quality.


None

ParticipantsAndreas Stratis, Leuven, Belgium (Presenter) Nothing to DiscloseGuozhi Zhang, Leuven, Belgium (Abstract Co-Author) Nothing to DiscloseReinhilde Jacobs, Leuven, Belgium (Abstract Co-Author) Nothing to DiscloseRia Bogaerts, Herestraat 49, Belgium (Abstract Co-Author) Nothing to DiscloseHilde Bosmans, PhD, Leuven, Belgium (Abstract Co-Author) Co-founder, Qaelum NV Research Grant, Siemens AG

PURPOSE

To estimate the uncertainty of calculated absorbed organ doses in dental Cone Beam CT (CBCT) Monte Carlo (MC) simulations dueto uncertainties in the measurement of Half Value Layer (HVL) and in the positioning of the Field of View (FOV).


X-ray tubes are applied to our EGSnrc MC framework via equivalent source models which consist of an energy spectrum derivedfrom HVL measurements and a filter description specified from air kerma measurements across the radiation field. The HVL of thePromax 3D Max scanner (Planmeca, Finland) was measured at 96 kV with a farmer ion chamber. Source models were generated forthe measured HVL and for HVL values corresponding to theoretical deviations of ± 2.5% and ±5%. In a first study, each spectrumwas directed towards the Zubal head phantom to simulate a jaw examination protocol (130 x 90 mm²). The centre of the FOV wasinitially placed between the upper and the lower jaw and axially positioned such that the entire denture is imaged. In a secondstudy, a fixed source model was directed ten times to the phantom, each time shifting the centre of the FOV by ±1 cm and ±2 cmin the front-back direction, 1cm diagonally, 1 cm back and 1 cm down.

RESULTS

The HVL at 96kV was 9.05mmAl. A 5% lower HVL value results in an average 34.4% overestimation in absorbed organ doses,whereas a 5% overestimation results in an average 33.02 % underestimation in calculated organ doses. The more the FOV is shiftedfrontwards (either on the midline or diagonally) the lower the doses get. Shifting the FOV down, there is a noticeable 35% doseincrease in the esophagus, a 28% dose increase in thyroid, a 29% decrease in brain and 29.62 % decrease in eye lens dose.

CONCLUSION

Underestimating HVL in the generation of equivalent source models procedure results in a thinner filter present on the beam pathand hence in higher doses. In cases of highly filtered beams, such as CT or CBCT, uncertainties of 5% in HVL and its implementationto source models intended for MC dose calculations lead to 34% over or under estimation of calculated organ doses. Similaruncertainties are obtained for misplacements of the FOV on the model.


SSG15-08 A Monte Carlo Dosimetry Comparison Study of Two Different Paediatric Protocols for Teeth AutoTransplantation Planning and Follow-up


SSG15-09 Is Simulation of 3D Tube Current Modulation Needed for Organ Dose Assessment with MCFrameworks?

Tuesday, Dec. 1 11:50AM - 12:00PM Location: S404AB

Accurate dental CBCT dose calculations in head voxel models via Monte Carlo simulations require accurate HVL measurements andcareful FOV positioning.

ParticipantsAndreas Stratis, Leuven, Belgium (Presenter) Nothing to DiscloseMostafa Ezeldeen, Leuven, Belgium (Abstract Co-Author) Nothing to DiscloseGuozhi Zhang, Leuven, Belgium (Abstract Co-Author) Nothing to DiscloseReinhilde Jacobs, Leuven, Belgium (Abstract Co-Author) Nothing to DiscloseRia Bogaerts, Herestraat 49, Belgium (Abstract Co-Author) Nothing to DiscloseHilde Bosmans, PhD, Leuven, Belgium (Abstract Co-Author) Co-founder, Qaelum NV Research Grant, Siemens AG

PURPOSE

To investigate via Monte Carlo (MC) simulations whether or not, a newly proposed autotransplantation tooth protocol in a newscanner, yielding images of similar quality with the existing protocol performed in an old scanner, is capable of reducing the dose topaediatric patients (justification).


The clinical protocol requires one high resolution treatment planning CBCT scan to guide the segmentation of the tooth to betransplanted and two follow-up scans, one and two years later. The current protocol in Accuitomo 170 (Morita, Japan) employs a60x60 mm2 'High Resolution' planning scan and two follow up 'Standard Resolution' 40x40 mm2 scans. The newly proposed one is tobe carried out in Promax 3D Max (Planmeca, Finland) using a planning scan (90x100 mm2), followed by two (50x55 mm2) scans (allof them 'Ultra low dose, normal reconstruction'). To compare organ doses, MC simulations in voxel phantoms were implemented. CTscans of three paediatric patients (5 and 8 years old male, 12 years old female) were used to segment internal anatomy and createpaediatric head voxel models. Three clinical dental applications (canine, incisor and premolar tooth) were investigated. An EGSnrcbased MC framework was calibrated and employed to calculate absorbed organ doses and effective dose (ED) for each paediatricvoxel phantom.

RESULTS

The total EDs of the currently used protocol for the 3 dental applications range from 356 µSv to 390 µSv for the 5 years old, 390 to402 µSv for the 8 years old and 270 to 288 µSv for the 12 years old phantoms. The new suggested protocol results in ED ranges of267 to 275 µSv, 242 to 246 µSv and 207 to 208 µSv for 5, 8 and 12 years old respectively. The contribution of the planning scanon the total ED is 70% on average with the current protocol in Accuitomo 170 and 50% with the newly proposed one in Promax 3DMax.

CONCLUSION

Effective doses for the new protocol are lower and it is therefore dosewise justified. The contribution of the follow up scans to thetotal ED suggests that the next step towards dose optimisation should investigate the dose reduction of the follow up scans evenfurther.


The newly proposed tooth auto transplantation protocol delivers lower doses to children compared to the currently used protocol

ParticipantsXochitl Lopez-Rendon, MSc, Leuven, Belgium (Presenter) Nothing to DiscloseGuozhi Zhang, Leuven, Belgium (Abstract Co-Author) Nothing to DiscloseWalter Coudyzer, Leuven, Belgium (Abstract Co-Author) Nothing to DiscloseWim Develter, Leuven, Belgium (Abstract Co-Author) Nothing to DiscloseHilde Bosmans, PhD, Leuven, Belgium (Abstract Co-Author) Co-founder, Qaelum NV Research Grant, Siemens AG Federica Zanca, PhD, Leuven, Belgium (Abstract Co-Author) Nothing to Disclose

PURPOSE

To estimate the error associated with breast and lung dose calculation when using longitudinal tube current modulation (TCM) onlyversus the full 3D TCM information for three chest CT protocols.


Four cadavers (3 female, 1 male) with different BMI (underweight, normal, overweight and obese) were scanned with a SiemensDefinition Flash CT scanner using Standard-, XCare- and Flash-protocols (120 kVp, TCM). CTDIvol was matched to the patientspecific CTDIvol of the Standard protocol for comparison purposes. The doses to the lungs and breasts were calculated with a MCsimulation framework (EGSnrc) by using the full 3D TCM information obtained from raw data versus the use of longitudinalmodulation only, obtained from DICOM headers. For each cadaver a voxel model was generated to be used for the dose calculation.

RESULTS

Results were analyzed per protocol and BMI. For the Standard protocol, independently of patient habitus, lung and breast dosedifferences between the two TCM methods were negligible (3.6% at maximum). For the XCare protocol, not accounting for theangular modulation caused a maximum underestimation of the lung dose for the underweight BMI of 1.6%. However, for the breastwe found an overestimation for the smaller BMI (7.0%) whereas the tendency reverted to an underestimation which increased withBMI (up to 14.4%). For the Flash protocol we found that the lung dose is underestimated for all BMI, with a maximum of 4.6% for

the underweight, decreasing to 0.7% for overweight, when considering only longitudinal TCM. For the breast, we found anoverestimation for the underweight BMI (3.3%), and a tendency to switch to underestimating values of 1.4% and 0.9% for thenormal and overweight BMI, respectively.

CONCLUSION

Lung and breast dose estimations with MC frameworks or commercial tools that implement only z-modulation are within 5% of therespective doses when simulating 3D TCM for chest CT scans using a Standard or a Flash CT protocol. For the XCare protocol, theuse of 3D TCM is recommended. This can be explained by the larger impact of the patient's anatomy and the particular tube currentmodulation scheme used for that protocol.


The implementation of longitudinal modulation only is sufficiently accurate for Standard and Flash CT protocols. This facilitatesorgan dosimetry estimation as 3D TCM is not accessible without the help of the manufacturer.

QS116-ED-TUA1

Leading Quality Improvement via Interinstitutional and Interdepartmental Collaboration in theManagement of Knee Osteoarthrosis: From X-ray to Arthroplasty

Station #1

QSE-TUA

Quality Storyboards Tuesday Poster Discussions

Tuesday, Dec. 1 12:15PM - 12:45PM Location: QS Community, Learning Center


Participants

Sub-Events

ParticipantsSusanna C. Spence, MD, Houston, TX (Presenter) Nothing to DiscloseWade McAlister, MD, Houston, TX (Abstract Co-Author) Nothing to DiscloseLeslie Turlington Moore, MBA, Houston, TX (Abstract Co-Author) Nothing to DiscloseMohammad Zare, MD,MS, Houston, TX (Abstract Co-Author) Nothing to DiscloseBrian C. Reed, MD, Houston, TX (Abstract Co-Author) Nothing to DiscloseBrigid A. Bingham, MD, Houston, TX (Abstract Co-Author) Nothing to DiscloseJason M. Low, MD, Houston, TX (Abstract Co-Author) Nothing to DiscloseMarc H. Willis, DO, Houston, TX (Abstract Co-Author) Nothing to Disclose

PURPOSE

In a large county healthcare system shared between two different (and sometimes competing) medical schools, management ofknee osteoarthrosis (OA) was inconsistent and expensive.This project was initiated by radiology, due to large numbers of knee OApatients getting MRIs for their advanced arthritic knees (ACR appropriateness: 1), with 32% of the knee MRIs inappropriate at thestart of the project.In an attempt to determine the reason for the inappropriate MRs, we engaged with our ordering primary carephysicians (PCPs), who felt the MRIs were needed for orthopaedic referral. The rejection rate for ortho referral for chronic kneepain/OA/DJD was 55%, and actually slightly worse in the pts who got knee MRIs. The perceived difficulty in documenting medicalnecessity for ortho referral was driving the utilization of MRI to 'prove' medical necessity, with the lack of success resulting infrustration.Adding to the PCP frustration, physical therapy (PT) in one portion of the institution was always available, but was oftenoverbooked at another site that was preferred by the pts living in that area. Those pts often called multiple times before getting anappointment, or simply stopped calling. Ortho had an extremely busy trauma service, with limited OR time for performing electivetotal knee arthroplasties (TKAs), although availability was improving. They were getting knee OA referrals for pts who had not yetcompleted conservative management, and therefore were wasting valuable clinic time to see pts whom they would immediatelysend back out for conservative treatment (therapeutic knee injections, PT etc). At this point, serious problems with radiologyexams, PCP referrals, PT availability and ortho workflow were all in play simultaneously, with an additional layer of complicationbeing that 2 different med schools were responsible for different halves of each of these depts.

METHODS

Walk the process: Workflow mapped from when the pt with chronic knee pain presented to the PCP, to their referrals and potentialend points.Evidence-based guidelines from the national societies (Ortho, Rheumatology and Family Medicine) and CMS guidelines onjustification of total knee arthroplasty were combined to create an evidence-based management protocol, agreed upon by ortho,primary care and radiology from both med schools.Radiology was right at the start of the clinical decision algorithm, with theinterpretation of weight-bearing knee xrays. This required putting in equipment capable of obtaining weight-bearing views in 2clinics, and in others obtaining step stools large enough to allow the chest bucky to be used. Radiologists from both medical schoolsthen issued a new, standardized report utilizing the validated Kellgren-Lawrence classification system, grading the knee arthritis. Ifa chronic knee pain pt already had moderate to severe (Kellgren-Lawrence grade 3 or 4) OA, no MRI was ordered, and theconservative management protocol was begun, which included at least 12 weeks of:1. Physical therapy or physician-directed self-management protocol2. NSAIDs (topical or oral) preferred, or tramadol3. Knee brace, cane, walker as indicated4. Intra-articularsteroid injection(s)5. Weight loss program if BMI >25 (although pt could be referred with BMI <35, a weight loss program should beinstituted in the overweight group)At the PT site with availability problems, group sessions for knee OA pts were instituted, allowing4 pts to be in the same room doing the same exercises. 2 additional staff were also hired due to general shortages. For pts who didnot want to (or could not) travel to a PT site, the PT team created a physician-directed sheet that would allow them to performtheir exercises at home. Either method was considered acceptable for eventual referral.

RESULTS

Program was instituted Aug 2014, with rollout continuing through Nov 2014. Endpoints included:# of weight-bearing x-rays orderedto allow grading of knee OA: ?~800%# of inappropriate MRIs: ? from 32% to 7% (saving ~ $10,000/month at CMS reimbursementrate, and saving time on our busy county magnets)# of ortho referrals (which should DECREASE for at least 12 weeks, as ptsshould be going to conservative management instead): ? by 17%Next available PT appt: 2 weeks for group knee OA pts, 3.5 weeksfor all comers# of TKAs/month: increased from 6 --> 24

CONCLUSION

Radiologists can successfully lead continuous quality improvement efforts within their institution regardless of the traditional cultureof the organization. By leading multidisciplinary collaboration, building diverse teams, communicating, providing standardized reportimpressions, and guiding patients through an evidence-based clinical algorithm, we can reduce waste and foster a culture ofcontinuous quality improvement. While complicated, the synergy of this project far exceeded what any of these individualinstitutions or departments could have accomplished working in their traditional silos.

QS118-ED-TUA2

Musculoskeletal Joint Injection Order Improvement

Station #2

QS120-ED-TUA3

Radiology Driving Change in Primary Care: The Diagnostic Imaging Appropriateness (DI-APP)Project

Station #3

ParticipantsJonelle M. Petscavage-Thomas, MD, MPH, Hummelstown, PA (Abstract Co-Author) Consultant, Medical Metrics, IncEric A. Walker, MD, Hershey, PA (Presenter) Research Consultant, Medical Metrics, IncDennis Duryea, DO, Harrisburg, PA (Abstract Co-Author) Nothing to DiscloseVictor Longo III, DO, Hershey, PA (Abstract Co-Author) Nothing to Disclose

PURPOSE

Image guided joint injections are a daily component of the radiologist's workflow. At our institution there was an incident casewhere the radiologist injected the tibiotalar joint, believing this was the intended location meant by "ankle". Unfortunately, thereferring provider had actually wanted the subtalar joint injected and the patient had to be recalled for a second injection. It wasdetermined that the electronic order consisted of a generic selection of "hip", "shoulder", "ankle", "knee", "elbow", "other". Thus,unless the provider wrote more detail about a specific site, it was unclear what was to be injected. For clarification, the radiologisteither had to review the medical record notes or page/call the provider to confirm intended site of injection. This added additionaltime to the workflow. Occasionally, the provider could not be reached and the radiologist was uncertain which location to injectand potentially had to assume or cancel the injection.This is a quality and safety issue as a joint injection is a minimally invasiveprocedure with risks of infection, bleeding, and contrast reaction. Thus, the purpose of this project was 1) determine thepercentage of unclear orders and number of wrong site injections over the quarter, 2) develop a solution of the electronicworkflow/order process, 3) implement the new workflow/orders, and 4) post implementation reevaluate the percentage of unclearorders and number of wrong site injections.

METHODS

A list of accession numbers from 200 joint injections performed under fluoroscopy by the musculoskeletal division prior to workflowchange was obtained from the radiology information system. These cases were reviewed to determine the following information:joint requested, vagueness of request - did it say shoulder vs. glenohumeral joint vs. bursa, actual site injected, any incorrect sitesinjectedThe ordering mechanism was changed within the electronic medical record such that generic terms of "hip", "ankle", and"shoulder" were no longer available to select. The following dropdown joint options were added so that the specific location isalways placed on the faxed request.Shoulder: glenohumeral joint, AC joint, Subacromial-subdeltoid bursa, otherAnkle: Tibiotalar,Subtalar, Talonavicular, otherHip: Hip, Trochanteric Bursa, iliopsoas bursa200 cases performed after the order change werereviewed in a mechanism similar to the pre-implementation cases.

RESULTS

Pre-implementation: Of the 200 requests analyzed, 23% (46) were vague (14 for small joints, 32 for large joints). This includedrequests for the "ankle" instead of specifying tibiotalar/subtalar or requests for "hip" and not specifying hip joint or bursa. Thus 23%of the time the radiologist had to do additional research to ascertain which location was to be injected. 2 out of the total 200injections analyzed were wrong site injections. One was a tibiotalar joint that was injected when the request called for a subtalarjoint injection. The second was a hip joint that was injected when the request called for a trochanteric bursa injection. Nocomplications occurred related to the wrong-site injections. Post-implementation: No wrong-site injections were found. Only1% (2)vague requests were identified. Both of these were in respect to which tarsometatarsal joints were to be injected. There was nonegative feedback from the referring physicians regarding the new ordering process.

CONCLUSION

A simple change in the information system has improved both patient safety and quality of care within the musculoskeletal radiologydivision. It has also improved workflow efficiency as 23-25% of the time we no longer need to do extra work to determine whichjoint is to be injected. This change should be applied to all joint related procedures, including aspirations and ultrasound guided jointrelated procedures.

ParticipantsJisla Mathews, Toronto, ON (Presenter) Nothing to DiscloseLilly Whitham, Toronto, ON (Abstract Co-Author) Nothing to DiscloseKaren Weiser, MBA, Toronto, ON (Abstract Co-Author) Nothing to DiscloseRavi Menezes, PhD, Toronto, ON (Abstract Co-Author) Nothing to Disclose

PURPOSE

Inappropriate diagnostic imaging (DI) can be defined as the use of imaging procedures when they have a small chance of affectingpatient management. The negative system-level consequences of inappropriate DI referral include increased wait times andincreased costs with no associated benefit for patients. While most referral guidelines aimed to reduce unnecessary imaging aredirected at primary care providers (PCPs), few guidelines have been developed with their dedicated involvement. The DIAppropriateness (DI-APP) Project was launched by our imaging department in 2014 as a regional initiative, involving multidisciplinarypanels led by PCPs, to develop pathways to guide imaging referral and promote evidence-based care for clinical scenarios thatpresent commonly in primary care.The goals of the project are as follows: Align clinically relevant, evidence-based DI guidelines todevelop Imaging Pathways for clinical scenarios that present commonly to primary care, such as headache and low back painDevelop recommendations for implementation and sustainability to ensure tools can be adopted into primary care practice andremain current with best evidence

METHODS

The DI-APP project approach combines methodological rigor and current evidence with physicians' expertise. The pathwaydevelopment process adopts elements of the CAN-IMPLEMENT framework, a streamlined version of the ADAPTE methodology forguideline adaptation[1].The Imaging Pathways are developed collaboratively by multidisciplinary panels that include PCPs,radiologists and other specialists. PCPs are strategically positioned as leads to ensure that the pathways are relevant to the endusers.Pathway development includes the following steps: Guideline Review (Project Team): A preliminary guideline search of Medline

QS122-ED-TUA4

High Fidelity Contrast Reaction Simulation Training: A Single Department's Experience in Training allFaculty, Fellows, and Residents to Improve Patient Care and Satisfy PQI Requirements

Station #4

and National Guideline Clearinghouse databases is conducted using keywords confirmed with panel leads. Abstracts and full-textarticles are screened via a blind dual review to shortlist relevant guidelines. Finally, a summary of imaging-related recommendationsis developed. Formulate Pathway Skeleton (Panel): Panel Leads draft an outline of the pathway Critical Appraisal of Guidelines(Project Team): Quality of each guideline's methodology is assessed by applying the Rigour of Development domain of the AGREE IIInstrument[2]. Online Panel Review of the Pathway Outline (Panel): Panel members are presented with recommendation summariesand critical appraisal scores and asked to rate their agreement that each guideline should be included in pathway development.Panel members are also asked to rate their agreement with the pathway outline. Panel Meeting to Finalize Pathway Design (Panel):Panel members are presented with the feedback from the online survey; areas of disagreement are discussed and documented.Addition of Levels of Evidence (Project Team): To determine the strength of evidence behind an imaging recommendation, theProject Team extracts the level of evidence when they are included in the guidelines. Consensus Building Process (Panel): Theconsensus-building process takes two rounds, following a modified Delphi process. First Round: Panel members review the pathwayonline and rate their agreement with the imaging recommendations. Second Round: Panel members discuss areas of disagreementand finalize the pathway. Pathway Finalization: The pathway is circulated electronically for final approval.[1]M.B. Harrison et al.CAN-IMPLEMENT Guideline Adaptation and Implementation Planning Resource, 2012[2]Brouwers M et al. AGREE II:Advancingguideline development, reporting and evaluation in healthcare. Can Med Assoc J.2010

RESULTS

Using the consensus-based methodology, DI-APP panel members successfully developed pathways for Low Back Pain and Headacheand will continue this work for Stroke, Knee Pain and Neck Pain.Over the past year's engagement, 55 clinicians in urban, suburbanand rural practice settings have come together to participate in this project. Strong clinician engagement has been a key successfactor and has been sustained over the course of many months, ranging from 80-90% meeting attendance. Survey response rateshave been consistently high as well, ranging from 70-80%.

CONCLUSION

The D-APP project has adopted an innovative approach to drive radiology into the future by positioning PCPs at the centre of thisimaging initiative. Over the project's duration, panel members have gained a better understanding of how imaging recommendationscan be improved and implemented in a manner that will lead to long-term acceptance in primary care.Recognizing that enablingeasy adoption of the pathways is crucial to making an impact on imaging referral practices, the DI-APP project engaged clinicians,administrative leaders and a patient representative to identify barriers and opportunities for adopting imaging pathways. Thisinformation will guide short-, medium- and long-term pathway implementation recommendations.

ParticipantsDaniella Asch, MD, New Haven, CT (Presenter) Nothing to DiscloseKyle E. Pfeifer, MD, New Haven, CT (Abstract Co-Author) Nothing to DiscloseJoseph Cavallo, MD, New Haven, CT (Abstract Co-Author) Nothing to DiscloseLiana Kappus, New Haven, CT (Abstract Co-Author) Nothing to DiscloseJennifer Arango, New Haven, CT (Abstract Co-Author) Nothing to DiscloseJonathan D. Kirsch, MD, New Haven, CT (Abstract Co-Author) Nothing to DiscloseJay K. Pahade, MD, New Haven, CT (Abstract Co-Author) Nothing to Disclose

PURPOSE

Contrast reactions are one of the few medical emergencies that radiologists must be prepared to manage. However, due to therelative rarity of severe reactions (0.005-0.01% of all injections), most radiologists have limited experience treating these patientsand knowledge of appropriate management algorithms is poor. This poses a significant risk in the event of an occurrence, withpotentially fatal patient outcomes. High-fidelity simulation has arisen as an effective model to address this issue as it allowspractice of high acuity but low frequency clinical events. To address any potential knowledge gaps, our institution implemented adepartment-wide quality improvement program designed to increase patient safety and radiologist education for the recognition andmanagement of contrast reactions. The quality improvement project was developed using the PDSA (Plan - Do - Study - Act) cycleadvocated by the American Board of Radiology (ABR).

METHODS

Four radiology staff (3 faculty, 1 resident) with an interest in contrast reaction management and education completed an 8-hourcourse on simulation development and instruction. All radiology residents and fellows were required to complete the simulationcourse. Training was optional for faculty but integrated into bonus eligibility to encourage completion. To assess knowledge, a 20-question multiple-choice test assessing participants' knowledge of contrast reactions/management and departmental contrastpolicies was developed based on the ACR contrast manual with 10 additional questions assessing participants' demographics,ACLS/BLS status, and comfort level in responding to contrast reactions using a Likert scale. The test was completed prior tosimulation training to allow assessment of knowledge prior to the intervention. Participants subsequently completed a one-hourcourse in our institution's high-fidelity simulation lab in mixed groups of 8-10 participants, with teams of 2-3 people serving as"initial responders" while others watched via live video feed. Three simulations were completed with predetermined end-points: amoderate severity contrast reaction requiring use of IM epinephrine, a high severity contrast reaction requiring use of IVepinephrine, and a hypoglycemic event mimicking a contrast reaction requiring blood sugar assessment and administration of anampule of D50. Each simulation was followed by a 5-10 minute debriefing session where participant events were discussed andappropriate treatment algorithms were reviewed. The same multiple choice and Likert scale test was re-administered within onemonth of simulation completion and at 6 months post simulation to assess program effectiveness and retention. The pre and posttesting was mandatory to receive credit for course simulation while the 6 month delayed test was optional. Pre- and post-simulation multiple choice test scores were compared with paired two-tail t tests, and Likert scores were compared using theWilcoxon signed rank test.

RESULTS

151 participants (103 males and 48 females) completed the pre and post test. Of the 151 participants, experience was as follows:13 (9%) were first year radiology residents (post-graduate year 2), 13 (9%) second year residents, 13 (9%) third year residents,13 (9%) fourth year residents, 24 (16%) fellows, 27 (18%) new faculty (0-5 years in practice), 9 (6%) faculty 6-10 years inpractice, 9 (6%) faculty 11-15 years in practice, and 29 (19%) were faculty with more than 15 years of practice. The mean overall

QS015-EB-TUA

Implementation and Results from Integrated Electronic Health Record Contrast Allergy DecisionSupport

Hardcopy Backboard

QS009-EB-TUA

The Impact of Time-of -Service Screening Resultson Workflow and Patient Satisfaction in anAcademic Breast Center

Hardcopy Backboard

score on the pretest was 14.1/20, which increased significantly to 14.5/20 in the posttest (p=0.03). 105 participants completedthe optional delayed posttest. Scores continued to significantly increase from pre and posttest (p<0.001 and p=0.001respectively), with a mean score of 15.3/20 on the delayed posttest. Likert scale scores measuring comfort level in managingcontrast reactions also showed a significant increase when comparing pretest and posttest scores (p<0.001) and pretest anddelayed posttest scores (p<0.001). However, comfort level showed a significant decline from the immediate posttest to the 6month delayed posttest (p=0.03). 86% of participants found high fidelity simulation to be an effective teaching tool. The projectwas successfully submitted as a department wide PQI project for ABR MOC requirements.

CONCLUSION

High-fidelity simulation is an effective tool to improve radiologists' knowledge and comfort in managing contrast reactions. Thetraining has now become an ongoing quality improvement project in our department, with all residents, fellows and facultyparticipating in the course annually. In addition, as comfort level declined at 6 months, in-situ simulation training has beenincorporated to allow knowledge refreshment 6 months after the simulation course. Development of a high-fidelity simulation projectto improve education on contrast reaction management is a high-yield initiative that also allows completion of a departmental widePQI project.

ParticipantsJonathan K. Lee, MD, Cleveland, OH (Presenter) Nothing to DiscloseWilliam C. Baughman, MD, Cleveland, OH (Abstract Co-Author) Nothing to DisclosePeter Greco, MD, Cleveland, OH (Abstract Co-Author) Nothing to DiscloseJonathan Siff, MD, Cleveland, OH (Abstract Co-Author) Nothing to Disclose

PURPOSE

Reduced revenues and patient satisfaction from cancellations and delays occur if the need for pre-medication in allergic patients isnot recognized before the patient arrives in the department. An electronic health record (EHR) contrast allergy best practice alert(BPA) was designed to immediately notify providers to an existing contrast allergy to reduce such events, as well as to improve theappropriateness of pre-procedural allergy orders by providing a standard prep order set.

METHODS

An alert smart-text was made in EPIC EHR, combining smartsets for adult inpatient, adult outpatient, pediatric inpatient, andpediatric outpatient orders. The smartset displayed when the order was placed before the order is signed specific for the patient'sage and context. A statistical analysis using the Student's T-test of prep order rates, exam order changes, and cancelled examsprior to and after BPA introduction was made.

RESULTS

BPA introduction was associated with an increase in frequency of otherwise unprompted prep orders from 46% (33/71) to 93%(26/28) and decreased the prep rate requiring radiology personnel intervention from 54% (38/71) to 7% (2/28) (p<0.0001).The BPAdid not significantly change the need for modification of prep orders or whether the exam was performed as ordered. The number ofexams converted from contrast to non-contrast was 32% (49/152) before the alert and 48% (38/78) after the alert (p=0.017). Therate of allergic reactions was unchanged. Day of exam cancellation rates decreased from 65% (65/100) to 42% (20/48) after BPAimplementation (p<0.0001).The observed increase in conversion rate from contrasted studies to non-contrast exams after BPAintroduction may be secondary to either clinician avoidance of prep complexity issues to obtain a suboptimal non-contrasted study,or due to lack of personalized instructions by the radiology resident to confirm contrast administration appropriateness despitepresence of an allergy. This lack of personal inter-departmental communication may be a disadvantage of BPAs.

CONCLUSION

Implementation of a contrast allergy decision support system in the EHR, maintained appropriate anti-allergy prophylaxis withreduced need for radiologist intervention and resulted in fewer same day cancellations improving patient satisfaction anddepartmental efficiency. The unanticipated decline in the frequency of contrast exams after BPA introduction requires furtherstudy, especially given national concern that EHR carry risks which are unique and specific to technology.Future work that can beimplemented to make this process even more efficient for the clinician and time saving for the patient include pulling in contrastallergies from patient input at home from MyChart or a RFID, and information sharing between different types of EHR. Also, makingthe clinician choose a reason for ignoring the alert could further enlighten us on reasons for decline in frequency of contrast exams.

ParticipantsJoanna Riegert, BS, Salt Lake City, UT (Presenter) Nothing to DiscloseMatthew Stein, MD, Salt Lake City, UT (Abstract Co-Author) Nothing to DiscloseNicole S. Winkler, MD, Salt Lake City, UT (Abstract Co-Author) Nothing to DiscloseMatthew B. Morgan, MD, Sandy, UT (Abstract Co-Author) Consultant, Reed ElsevierLuca Boi, Salt Lake City, UT (Abstract Co-Author) Nothing to Disclose

PURPOSE

Delay in receiving the results of a screening mammogram, which is typically around 6 days, is a major source of anxiety (harm) forthe screening population. Decreasing the time to exam results serves as a surrogate target intervention for reducing harm. Ninety-seven to ninety-eight percent of women can be given a normal result at a single visit by providing routine and additional diagnosticstudies deemed necessary at the time of the initial screening encounter. Baseline analysis identified causes of delay, and theproject focused on reducing the time to results to the patient from an average of 6 days to less than 15 minutes for participatingpatients. Currently, the program is expanding to include 3 additional off-site screening-only facilities. Potential negative impacts onworkflow and quality metrics were minimized or avoided altogether. Resident and fellow teaching has been enhanced as the

attending MD and trainee perform real-time double reading and maintain continuity of care of patients from screening exam thoughthe diagnostic work-up, including same-day biopsy of BI-RADS 4 and 5 findings. Time-of-service screening mammography programbenefits the two to three percent or patients that are ultimately recommended for biopsy by resulting in same day biopsy; thiscondenses two or three potential visits to one and shortens the wait time to final histology results of the core needle biopsy.

METHODS

A time-of-service screening mammography process was implemented at the main facility. Upon arrival patients are asked if theywould like to wait for 10 minutes while the Radiologist reads the study, and a result letter will be presented during the sameappointment. If patients say yes, the patient will remain in the department in a consult room until the exam has been reviewed andresults provided. The attending physician and resident/fellow review the imaging, a report is entered into the MammographyInformation System, and a results letter is printed and provided to the patient. If additional evaluation is necessary, it is orderedand completed in the same appointment, up to and including biopsy in most cases, unless there is a patient or scheduling conflict.

RESULTS

97-98% of participating women receive final normal results the same day; those needing biopsy receive the biopsy the same day orare scheduled for the next available appointment. Average wait times to final normal result went from 6 days to less than 15minutes for participating patients. Program has had no adverse effect on false positive interpretation rate or resident/fellowtraining, and was achieved with existing personnel and equipment at no additional cost. Potential savings to institution/environmentinclude postage and condensing multiple patient visits to one. High cancer detection rate and top-of-measure patient satisfactionscores are unchanged (although many positive comments now directly reference the program). There has been a slightimprovement in efficiency, with more screens per month being read (~5% increase).

CONCLUSION

Patient anxiety resulting from awaiting exam results is a significant and avoidable harm of screening mammography programs.Implementing a time-of-service screening mammography intervention has had multiple positive and no negative effects on a busyacademic breast imaging practice. Providing a time-of-service screening mammography intervention has made a significant impacton reducing harm; this conclusion is supported by continued top patient satisfaction scores directly referencing the program.Potential pre-implementation concerns for higher recall rate and decreased efficiency were not realized. Secondary benefits includeenhancing the teaching experience by providing same-day continuity of care to the interpreting physician and trainee andshortening wait times for histology for the small proportion of patients who will ultimately need a biopsy as part of their imagingwork-up.

QS117-ED-TUB1

Adapting the Universal Protocol in a Diagnostic Radiology Department to Help Prevent Wrong Patient,Wrong Site, and Wrong Examination Events

Station #1

QS119-ED-TUB2

Quality Control and Management of Personal Protective Equipment within a Large Health Care Region

Station #2

QSE-TUB

Quality Storyboards Tuesday Poster Discussions

Tuesday, Dec. 1 12:45PM - 1:15PM Location: QS Community, Learning Center


Participants

Sub-Events

ParticipantsAlan M. Kantor, MD, Bronx, NY (Abstract Co-Author) Nothing to DisclosePaul P. Moh, MD, Fort Lee, NJ (Abstract Co-Author) Nothing to DiscloseFrancisco Mercado, Bronx, NY (Abstract Co-Author) Nothing to DiscloseBalavenkatesh Kanna, MD, Bronx, NY (Abstract Co-Author) Nothing to DiscloseAdam M. Herder, MD, New York, NY (Abstract Co-Author) Nothing to DiscloseDaniel D. Droukas, MD, Bronx, NY (Presenter) Nothing to Disclose

PURPOSE

In 2008, "improving the accuracy of patient identification" was established as a Joint Commission National Patient Safety Goal(NPSG). Patient misidentification is a factor contributing to errors in medication administration, invasive procedures, bloodtransfusions, provision of emergency medical services and diagnostic imaging. We are a 350 bed inner city hospital and level onetrauma center that performs approximately 180,000 diagnostic imaging studies per year. Between April 2013 and June 2014 anunusual cluster of wrong-patient, wrong-site, and wrong-examination events occurred involving diagnostic imaging studies from thewards, the emergency room and the critical care areas. In response, a multi-disciplinary group of physicians, nurses, clerks,technologists, and organizational leaders collaborated to design and implement a hospital-wide Quality Improvement (QI) initiative.

METHODS

Root Cause Analysis (RCA) of the occurrences and Failure Modes and Effects Analysis (FMEA) were used to expose severalvulnerabilities in the patient site and examination verification processes. Plan Design, Study, Act (PDSA) methodology was thenused to test and implement the proposed changes. Radiology Exam Verification ("time-out") forms were created requiring thepatient's name, medical record number, date of birth, and Radiology accession number to be completed by the RadiologyTechnologists (RTs) prior to the initiation of any diagnostic imaging study with the exception of studies involving clinically unstableor trauma patients at initial presentation. Additionally, these forms required documentation of the planned diagnostic imagingmodality and anatomical site verification which for CT scans required a two person verification system. This system mandated theRT and an accompanying witness (Nurse, PCA, or physician) be present during the patient, site, modality identification process,with attestation that the process had occurred in the proper sequential order via the RT and witness documenting their respectiveinitials side-by-side after completion of every step listed on the Verification form.Compliance was initially monitored through thedaily review of verification forms by radiology administrators. Any improperly completed or incomplete verification forms weredeemed and labeled as fall-outs. An audit of more than 5000 exams was completed ensuring accurate documentation and examshad occurred. Extensive in-service education to all departmental staff and an occurrence reporting protocol was put in place.

RESULTS

The Radiology Exam Verification forms were created in June of 2014 and implemented in early July 2014. In late July of 2014 twosubsequent imaging errors occurred: one in CT and one in plain films both involving wrong-site imaging. A second RCA of theseoccurrences revealed that the entire process had been performed correctly but both involved a significant delay between theverification process and the time the actual imaging occurred. Starting in August 2014, repetition of the verification process wasrequired in the event that any significant delay in imaging had occurred. In addition, the requested site was to be marked with non-invasive adhesive tape, similar to that of pen marking prior to a surgical procedure and the two person verification process wasinstituted throughout the department.Staff education with meetings, conferences and huddles was repeated. Compliance andmonitoring of the process was changed from review of completed forms to random direct observation. Within two months, fall outsfell to zero for those directly observed. More importantly, since implementation we have not experienced a wrong patient, wrongexamination or wrong site error in over 200 days corresponding to over 100,000 examinations.Review of the FMEAs revealed anadditional point of vulnerability at the point of order entry by the requesting clinician. In addition to alerting the referring clinician ofthe wrong site, wrong exam order which had always been done, a log of these "good catches" was maintained by the technologistsfor review with service chiefs. This has resulted in a significant decrease in the number of incorrect orders since implementation.

CONCLUSION

It is estimated that over 1 billion diagnostic imaging examinations are performed in North America each year. Adapting the NPSGUniversal Protocol has helped prevent wrong-patient, wrong-site, and wrong-examination events involving diagnostic imaging in ourinstitution for greater than 6 months and counting at the time this was authored at our institution. While further studiesinvestigating the clinical benefit of the above intervention on a local and more global scale are required, the quality improvementinitiative revealed that simply adapting the Universal protocol for a diagnostic Radiology department can effectively reduce the riskof wrong-patient, wrong-site, and wrong-examination events at a busy urban hospital center.

ParticipantsPetar Seslija, MSc, Vancouver, BC (Presenter) Nothing to DiscloseRobert Cropp, PhD, Vancouver, BC (Abstract Co-Author) Nothing to Disclose

QS121-ED-TUB3

Fostering a Culture of Safety for an Out-patient Musculoskeletal Radiology Interventional Service in aLarge Urban Teaching Hospital via a Standardized Approach to Pre-procedure Preparation

Station #3

Kevin Hammerstrom, Vancouver, BC (Abstract Co-Author) Nothing to DiscloseHenry Ross, New Westminster, BC (Abstract Co-Author) Nothing to DiscloseTrudy Pel, Vancouver, BC (Abstract Co-Author) Nothing to DiscloseYogesh Thakur, PhD, Vancouver, BC (Abstract Co-Author) Nothing to Disclose

PURPOSE

Annual inspection and documentation of personal protective equipment (PPE) is a mandatory requirement under the accreditationbody which accredits medical imaging facilities in our region, and is recommended by our federal health and safety standards.Traditionally, hand-written logs were common practice for documenting annual inspection results for PPE. However, these logs donot facilitate precise identification of PPE, or a continuous record of quality control. A more efficient form of documentation andidentification was required to effectively meet our accreditation standards. In recent years, a growing number of lead-compositeand non-lead materials for PPE have entered the marketplace. Evaluation of these new materials plays an important role in ensuringthe radiation safety of medical imaging staff and patients. In order to effectively manage PPE in a large health care region, acomprehensive quality control program was developed and implemented. The program includes the evaluation of new shieldingmaterials, acceptance testing of newly ordered PPE, and the development of a barcode inventory system to facilitate uniqueidentification of all PPE in the region, and efficient documentation of annual inspections.

METHODS

Evaluation of new shielding materials used in PPE was performed by comparing their primary broad-beam x-ray transmission with99.95% pure lead foil over a range of diagnostic energies (50 to 130 kVp). Acceptance criteria for the attenuation properties ofnew PPE material was determined by calculating an equivalent lead thickness based on a fitted model of the pure lead foiltransmission measurements. Any new shielding materials that fail to meet minimum lead equivalence criteria are not recommendedfor use by hospital personnel.Acceptance testing on newly ordered PPE includes transmission testing of a sampling of items basedon shielding lot number to ensure shielding quality, and visual and fluoroscopic inspection of all new PPE to inspect formanufacturing defects. Items with defects are flagged to be sent back to the manufacturer for repair or replacement. Annualinspections are performed in accordance with our federal standards, which recommend any PPE having a total aggregate defectivearea greater than 670 mm2 or a 5 mm diameter defect in the vicinity of the thyroid or reproductive organs, be removed from use.An inventory system, which includes a graphical user interface, was developed in Microsoft Excel using the visual basicdevelopment tools. Once a batch of PPE has been accepted into the hospital it is tagged with a data matrix barcode button andscanned into the inventory system. Information regarding the PPE, including its associated department, manufacturer's details,manufacture date, garment type and colour, shielding type, serial and lot numbers, and specified lead equivalence, is logged.Results of the initial visual and fluoroscopic inspections are documented inventory system for future reference. Subsequent annualinspections are logged into the system such that the quality control history for each PPE garment is continually updated.

RESULTS

The continued evaluation of newly introduced shielding materials for use in PPE has resulted in a database of recommendedmanufacturers and materials that medical imaging facilities in the region can reference when ordering new PPE for staff. Figure 1ashows the broad beam transmission of different PPE products and materials over the diagnostic energy range in comparison with 0.5mm of pure lead foil.Acceptance testing of newly ordered PPE has helped ensure the quality of shielding batches and in someinstances has identified problematic PPE which originated from a single manufacturing lot number (Figure 1b).At the current momentthe inventory system (Figure 1c) has been implemented in 14 hospitals throughout our healthcare region, with more than 1500 PPEitems logged into the system. The system was implemented at a fraction of the cost of comparable commercially availableproducts, and has the additional benefit of keeping data in-house as opposed to third-party cloud-based options. With the use ofunique data matrix barcode identifiers (Figure 1d), every piece of PPE is individually identified and tracked, in terms of ensuringcompliance to yearly inspection requirements. The system facilitates documentation of the inspection date, inspector initials, andinspection results of each annual inspection performed. This information is stored within the inventory database, and keptthroughout the lifetime of the item. The QC history of each PPE item is easily accessible through the search functions of theinventory system, which facilitates spot inspections during the accreditation process.

CONCLUSION

With the implementation of new material evaluations, acceptance procedures, and an inventory system for PPE the health region iseffectively meeting its PPE quality control requirements for medical imaging accreditation.

ParticipantsSanaz Javadi, MD, Houston, TX (Abstract Co-Author) Nothing to DiscloseMarc H. Willis, DO, Houston, TX (Presenter) Nothing to Disclose

PURPOSE

Foster a culture of safety through a quality improvement project. Develop a practical and sustainable system to reduce unexplainedvariance in pre-procedural preparation for a busy out-patient musculoskeletal interventional radiology service.

METHODS

We utilized the Institute for Healthcare Improvement's (IHI) Model for Improvement. The project leaders initially met to perform aneeds assessment, define the scope of the project and identify potential barriers. A failure mode and effects analysis (FMEA) wasperformed to identify potential issues that could result in patient harm. We identified key safety items, including: patientidentification, marking the site of the procedure, reviewing prior imaging, laboratory results (PT/INR, PTT, CBC), allergies,anticoagulants and safety timeout as being important for these procedures.A staff radiologist and lead technologist performed aprospective quality evaluation on 11 musculoskeletal procedures, a similar role to "secret shoppers", collecting data regardingresident compliance with checking, verifying and performing each of the safety items listed above.During the initial FMEA, weidentified that identification wrist bands had not been added to the out-patient MSK workflow when they previously had beenadded to the body IR and neuro IR workflows per Joint Commission guidelines. Administration quickly corrected this workflowoversight.A safety checklist was developed and incorporated in the pre-procedure note in the electronic medical record system foreach of the key safety items targeted for this project. Residents were educated regarding how to use the safety checklist, verifythe correct patient identification, mark the site of the procedure and perform a safety timeout. Multiple reminder signs were placed

QS123-ED-TUB4

Reducing Variability in Orthogonal Reformatted Image Quality from Long Z-axis CT AngiographyStudies Using Multi-vendor 3D Post-Processing Toolkits

Station #4

at the entry point into the procedure rooms.A post-intervention quality evaluation was performed by the same staff radiologist andlead technologist, also using a "secret shopper" approach. The first pre and post data collection were performed at the beginningand end of the same month while the same residents were on service. The post-intervention observation was on 11 procedures.Each month, the on-coming residents are oriented to the new system by the rotation supervisor. To assess the sustainability of themethod, a third round of quality evaluations were performed 2 months later on 8 MSK procedures performed by different group ofresidents.

RESULTS

For both the pre and post checklist analysis, the relevant data were evaluated based on total number of procedures and subsets oftargeted safety items to safely perform out-patient musculoskeletal interventional procedures. On the pre-checklist analysis, only18 out of 44 (41%) safety items were addressed by the resident performing a procedure. The most common information notreviewed prior to the procedure before implementing the checklist were the relevant laboratory results. On the post-checklistanalysis, the safety items were addressed 100% of the time, both the month of the initial implementation and three months laterwith a different group of rotation residents.

CONCLUSION

We demonstrated at a large teaching hospital with a busy musculoskeletal interventional radiology service, a quality improvementproject can successfully implement a systematic approach to procedure preparation via standardized safety checklist, pre-procedure documentation and safety timeouts, laying the foundation for building a culture of safety.

ParticipantsErica B. Stein, MD, Ann Arbor, MI (Presenter) Nothing to DisclosePeter S. Liu, MD, Ann Arbor, MI (Abstract Co-Author) Nothing to DiscloseMatthew S. Davenport, MD, Cincinnati, OH (Abstract Co-Author) Book contract, Wolters Kluwer nv; Book contract, Reed Elsevier; Karen Barber, Ann Arbor, MI (Abstract Co-Author) Nothing to DiscloseElla A. Kazerooni, MD, Ann Arbor, MI (Abstract Co-Author) Nothing to Disclose

PURPOSE

Interpretation of CT angiography requires evaluation of both luminal narrowing and length of stenosis in order to accurately triagepatients to the correct treatment strategy. Because the vessels are often oblique to the axial plane of CT scan acquisition, coronaland sagittal reformatted images are critically important to make these assessments, particularly in runoff studies. Our goal was todetermine and reduce the variability in image quality of orthogonal reformatted images generated from long Z-axis arterial runoff CTangiography studies of the upper and lower extremities.

METHODS

Institutional review board approval was waived for this HIPAA-compliant departmental quality improvement project. A listing of allCT angiography (CTA) studies of the upper or lower extremities performed within a single academic healthcare system wasgenerated by searching the radiology information system records for applicable CPT codes. Analyzed exam data consisted of studiesperformed between 3/1/2014 and 3/31/2015, which included 8 months of data prior to the first PDCA cycle to establish historicalperformance (baseline period). All studies were reviewed on PACS by either a senior house officer (PGY-5 radiology trainee) orattending abdominal imaging radiologist with 7 years of experience. Study quality markers were assessed by direct review of theimaging data and interrogating the DICOM header data, including: (1.) whether sagittal and coronal reformatted images wereperformed; (2.) if a high-resolution technique/matrix was used; and (3.) if the images were in a distance-measurable image format.A correctly performed study was defined as meeting all three of the study quality criteria. The proportion of correctly performedstudies was determined on a monthly basis and an iterative root-cause analysis for sources of error was performed. Both humanand technical factors were determined to contribute to impaired image quality, and several corrective actions were implementedduring consecutive PDCA cycles. These actions included education with 3D technologists in a hands-on workshop, lecture materialabout the clinical relevance and importance of orthogonal imaging, interrogation of individual 3D workstations, collaboration withmultiple 3D vendors about thin-client technical problems, and a leadership meeting to discuss target goals for reformatted imagequality. A statistical process control chart (p-chart) was generated to demonstrate longitudinal results.

RESULTS

During the baseline period, the monthly rate of correctly performed studies ranged from 32% (17/53 studies) to 51% (20/39studies), with a mean of 41 +/- 6% SD. During the first PDCA cycle after in-service training and lecture material, the monthly rateof correctly performed studies ranged from 40% (16/40 studies) to 59% (24/41 studies), with a mean of 49 +/- 13% SD. During thesecond PDCA cycle after several technical issues were identified (multi-vendor 3D client software version control and vendor-specific software setting adjustments) and addressed, the rate of correctly performed studies was 80% (33/41 studies) to 82%(31/38 studies), with a mean of 81 +/- 5%. Upper and lower control limits were shifted upward after the second PDCA cycle (Figure1).

CONCLUSION

Substandard, variable, non-measurable reformatted images resulting from long Z-axis CTA studies can be substantially improvedwith iterative PDCA cycles. Through a variety of educational, operational, and software improvements, both human and technicalfactors were addressed. Improvement in technical factors resulted in the most substantial gains in study uniformity.

Honored Educators


Ella A. Kazerooni, MD - 2014 Honored Educator

QS006-EB-TUB

The RITE Program: Use of a Team-Based, Project-Based Multidisciplinary Quality ImprovementCourse to Facilitate Improvement in an Academic Radiology Department

Hardcopy Backboard

Participants

David B. Larson, MD, MBA, Los Altos, CA (Presenter) Intellectual property license agreement, Bayer AG; Potential royalties, BayerAGJake Mickelsen, BS, Stanford, CA (Abstract Co-Author) Nothing to DiscloseKandice Garcia, RN, MS, Stanford, CA (Abstract Co-Author) Nothing to Disclose

PURPOSE

The purpose of this program was to develop and implement an academic radiology departmental course that simultaneouslyfacilitates the successful completion of quality improvement (QI) projects and provides an effective practical education in QImethods using a team- and project-based model.

METHODS

A 10-session, 20-week course (Radiology Improvement Team Education, or RITE course) was developed and implemented in theradiology department, with strong support from both the hospital and medical school leadership. Eight projects were commissionedfor the course based on projected costs and benefits of each project. Teams were assembled for each project; each team includeda team leader, 3-7 project participants, a sponsor, and a QI coach. Each session lasted two hours; lunch was provided for allparticipants. Didactic material was presented in a "flipped classroom" style, with 28 short videos (5-15 minutes) made availableonline prior to each session and with 30 minutes of discussion and review during the session. Each team was also expected to sharea book report based on their choice of a variety of QI-related books. Teams were instructed in how to frame their problem in an"A3" format, with the following sections: problem statement, background, current state (including annotated run chart), SMARTgoal, analysis, key drivers, interventions, and sustain plan. Each team was expected to share an update of their project at thesessions, receive feedback on their approach, and provide feedback to others. Project progress was tracked using a projectprogress scale with scores from 1-5 (Fig. 1). Team coaches met separately with the course director and with department leaderson a weekly basis to review project progress, identify barriers, and remove barriers as needed. A survey of was administered at theend of the course in which participants provided a self-assessment of their skills prior to and at the end of the course on a 1-6scale (1=no knowledge, 2=basic knowledge, 3=basic application, 4=analysis and application, 5=highly experienced, and 6=expert).Participants were also surveyed regarding overall satisfaction as well as the helpfulness of specific elements of the course on a 1-5scale (1=highly dissatisfied, 2=dissatisfied, 3=ambivalent, 4=satisfied, and 5=satisfied).

RESULTS

A total of 41 individuals participated in the course, including 9 administrative leaders, 9 residents/fellows, 7 technologists, 6 facultyphysicians, 5 administrative staff members, and 5 nurses. Additionally, 6 individuals from outside the radiology departmentparticipated, including 2 neurologists, 2 stroke coordinators, 1 emergency department nurse, and 1 lead transporter. The coursewas led by a radiologist (associate department chair) and two QI coaches. Projects included improving mammography positioning,decreasing MRI missed appointments, improving communication with clinicians, ED stroke code response time, improving MRIcapacity and efficiency, improving adequacy of clinical histories, reducing wait time for inpatient transfers, and improving efficiencyof MRI protocols. The average project progress score increased from 1.4 (out of a possible 5) to 4.0/5, with 6 of the 8 projectsachieving substantial improvement and 3 of the 8 projects achieving sustained substantial improvement by the completion of thecourse (Fig. 1). Average self-assessment scores for each skill increased from a median of 2.53/6 to 4.45/6, with the greatestimprovements in the ability to develop a SMART goal, use of A3 thinking, and effectively using a key driver diagram. Participantsreported an average helpfulness of all course elements of 3.6/4, with highest rated elements reported to be the use of a run chart,use of the A3 template, and QI coaching between sessions. Average overall satisfaction score was 4.7/5. Average traineesatisfaction was 3.8/5; average satisfaction of non-trainees was 4.8/5.

CONCLUSION

The multidisciplinary RITE course was effective in simultaneously facilitating the execution of multiple departmental improvementprojects and improving participants' self-assessed skills in QI methodology. Total time spent in class was 20 hours, with half of thattime occurring during the lunch hour. Participants reported a high level of satisfaction, though trainee satisfaction was lower thanthat of other participants. Future efforts will focus on making the course more helpful to trainees and on deploying the modelelsewhere in the medical center.

Honored Educators



MSAS33A Dose Optimization in Pediatric Cardiology

MSAS33B Learning from Errors and Near-Misses

MSAS33

Radiation Safety and Dose Optimization (Sponsored by the Associated Sciences Consortium) (An InteractiveSession)

Tuesday, Dec. 1 1:30PM - 3:00PM Location: S105AB

CA PD SQ


ParticipantsRichard Evans, London, United Kingdom (Moderator) Nothing to DiscloseLouise Coleman, London, United Kingdom (Moderator) Nothing to Disclose

Sub-Events

ParticipantsSonyia L. McFadden, MD, Antrim, United Kingdom, ([email protected]) (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Comprehend current levels and risks of radiation exposure in Paediatric Interventional Cardiology (PIC). 2) Be able to calculateLocal Diagnostic Reference Levels (LDRL). 3) Identify the different Interventional cardiology (IC) protocols currently used acrossthe UK/Ireland and their impact on radiation dose/image quality. 4) Apply best practice in PIC.

ABSTRACT

PURPOSEThe number of pediatric interventional cardiology (PIC) procedures being performed has increased rapidly in recent yearsdue to their reliability and cost effectiveness. However, interventional cardiology procedures have been reported to contribute tothe highest doses of radiation to patients from medical examinations. Previous authors have estimated DRL for PIC and identified awide variation of radiation exposure to the patient.METHOD AND MATERIALSA questionnaire study was used to investigate the PICprotocols currently used in clinical departments. Experimental studies were performed on anthropomorphic phantoms investigatingthese different variations in practice and the subsequent effect on image quality and radiation dose. A subsequent randomisedcontrolled trial investigating these different protocols and their effect on image quality and dose is currently ongoing in the clinicalenvironment. The effect of different scatter removal techniques on radiation dose and associated DNA damage was alsoinvestigated by quantifying γH2AX-foci as a biomarker of radiation-induced effect.RESULTSWide variations in imaging protocols arecurrently being used across different hospitals. These variations in practice are having a significant impact on the resultantradiation dose to the patient. Results of experimental studies on anthropomorphic phantoms showed that radiation dose reductionsof 30% to 50% could be achieved by removing the anti-scatter grid, introducing an air gap and decreasing the frame rate withminimal impact on image quality. Radiation induced DNA damage is evident in patients undergoing PIC procedures and mean γH2AX-foci can be significantly greater in different hospitals depending on the protocol used.CONCLUSIONGreat variation in radiationexposure exists across hospitals performing similar examinations on similar sized patients. There is a clear need for standardisedprotocols and guidelines.The anti-scatter grid should be removed routinely for newborn and infant patients undergoing PIC. The airgap should be introduced when possible.CLINICAL RELEVANCE/APPLICATIONSimple modifications to clinical protocols will ensure theradiation dose to pediatric patients is kept ALARA without affecting image quality or diagnostic efficacy.

ParticipantsSarah Peters, Didcot, United Kingdom, ([email protected]) (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Identify common causes of errors and near-misses in the UK. 2) Describe the way errors and near-misses are investigated andreported in the UK. 3) Compare several approaches to disseminating learning from errors and near-misses.

ABSTRACT

Healthcare professionals have a duty to inform their employer when things go wrong, regardless of whether it leads to actual harm.In turn employers should create an environment where staff members are supported and encouraged to report errors and near-misses.The World Health Organization (WHO) defines an error as "the failure of a planned action to be completed as intended or theuse of a wrong plan to achieve an aim. Errors may be errors of commission or omission, and usually reflect deficiencies in thesystems of care".The first stage in learning from an error is to investigate not just the 'who was involved, what happened andwhen?' but more importantly the 'why did it happen?' These investigations should seek to establish the facts surrounding the errorrather than apportion blame, unless there was obvious malicious intent. Error investigations should also include recommendationsand changes to systems of work and procedures that will lead to improvements in patient safety and prevent recurrence.For everyerror or incident, many more near misses will occur. The reporting and subsequent investigation of near misses can reduce thechances of an actual error occurring.No system is perfect, especially when human beings play an integral part in the process. Thekey point is that when errors and near-misses occur, organisations and individuals must learn from them and also ensure that thislearning is shared. This could be on a local, regional or even national level to avoid the same mistake happening over and overagain, at multiple locations and impacting the lives of numerous patients.This presentation will look at common errors and near-misses from a UK perspective as well as a number of approaches that are used both locally and nationally to ensure that learning isshared amongst the Radiology community.

MSQI33A Pitfalls to Avoid with Project Design

MSQI33B Pitfalls to Avoid with Project Execution

MSQI33C How to Meet and Pass the American Board of Radiology Practice Quality Improvement (PQI)Requirements and Audit

MSQI33

Quality Improvement Symposium: Common Mistakes in Practice Quality Improvement

Tuesday, Dec. 1 1:30PM - 3:00PM Location: S406B

SQ


ParticipantsDavid B. Larson, MD, MBA, Los Altos, CA, ([email protected]) (Moderator) Intellectual property license agreement, BayerAG; Potential royalties, Bayer AG

LEARNING OBJECTIVES

1) Understand common reasons why practice quality improvement projects tend to fail. 2) Understand strategies to anticipate andovercome pitfalls to successfully complete practice quality improvement projects. Attendees scoring 80% or higher on the SAM testmay earn a Quality Essentials Certificate in the "Quality Improvement in Your Practice" domain.

ABSTRACT

Meaningful quality improvement requires meaningful organizational change. Change efforts can fail for a variety of reasons. In thissession, authors will discuss common reasons why improvement efforts tend to be unsuccessful, and provide strategies forincreasing the likelihood of success.

Sub-Events

ParticipantsDavid B. Larson, MD, MBA, Los Altos, CA (Presenter) Intellectual property license agreement, Bayer AG; Potential royalties, BayerAG

LEARNING OBJECTIVES

1) Understand common pitfalls associated with Practice Quality Improvement design and how they can derail a project. 2)Understand strategies to anticipate and successfully overcome these pitfalls. Attendees scoring 80% or higher on the SAM testmay earn a Quality Essentials Certificate in the "Quality Improvement in Your Practice" domain.

ABSTRACT

Like with any meaningful project, the success of a PQI project depends to a large extent on project preparation and design. Theauthor will discuss common pitfalls associated with PQI project design and strategies for anticipating and overcoming them toincrease the likelihood of project success.

Honored Educators



ParticipantsJames V. Rawson, MD, Augusta, GA (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Review reasons projects fail. 2) Review tools to avoid projects not meeting goals. Attendees scoring 80% or higher on the SAMtest may earn a Quality Essentials Certificate in the "Quality Improvement in Your Practice" domain.

ABSTRACT

Performance improvement projects can be well conceived but fail at the implementation or execution stage. Such failures oftenoccur for predictable and hence avoidable reasons. The author will discuss reasons for failed executions and potential tools to helpprojects meet goals.

ParticipantsDavid Laszakovits, MBA, Tucson, AZ (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Understand the Essential Elements of a PQI project. 2) Understand the participation options for fulfilling the PQI requirements. 3)Understand what documentation needs to be provided to the ABR in the event of an audit. Attendees scoring 80% or higher on theSAM test may earn a Quality Essentials Certificate in the "Quality Improvement in Your Practice" domain.

ABSTRACT

The ABR requirements specify that each diplomate complete at least one PQI project every three years. The author will discuss theessential elements of a PQI project, the various options for participation and what documentation should be retained for auditpurposes.

SSJ08-01 Low Dose Gemstone Spectral CT Imaging in Abdominal Patients: Evaluation of Whether the VirtualNon-enhanced Images from Contrast-enhanced Spectral CT Could Replace True Non-enhanced forRadiation Dose Reduction

Tuesday, Dec. 1 3:00PM - 3:10PM Location: E352

SSJ08-02 Evaluation of Contrast Enhancement and Image Quality: A Comparison Study between Different TubeVoltages and Iodine Concentrations in Upper Abdominal Dynamic CT Scans in Minipigs


SSJ08

Gastrointestinal (CT Dose Reduction)


CT GI SQ



ParticipantsVahid Yaghmai, MD, Chicago, IL (Moderator) Nothing to DiscloseMannudeep K. Kalra, MD, Boston, MA (Moderator) Nothing to Disclose

Sub-Events

ParticipantsHai-Feng Duan, MMed, Xianyang, China (Presenter) Nothing to DiscloseYongjun Jia, MMed, Xianyang City, China (Abstract Co-Author) Nothing to DiscloseTaiping He, Xianyang, China (Abstract Co-Author) Nothing to DiscloseZhanli Ren, Xianyang, China (Abstract Co-Author) Nothing to DiscloseXirong Zhang, Xianyang, China (Abstract Co-Author) Nothing to DiscloseYong Yu, Xianyang City, China (Abstract Co-Author) Nothing to DiscloseYoumin Guo, Xian, China (Abstract Co-Author) Nothing to DiscloseYang Chuangbo, MMed, Xianyang City, China (Abstract Co-Author) Nothing to Disclose

PURPOSE

To evaluate if the virtual nonenhanced (VNE) images generated from the contrast-enhanced low dose spectral CT images couldreplace the true nonenhanced (TNE) for radiation dose reduction.


Images of 50 consecutive adults (36 males and 14 females, ages: 21-79 years) who underwent 3-phase abdominal CT wereretrospectively analyzed. TNE CT was performed with conventional 120kVp. The contrast-enhanced scans in arterial phase (AP)and portal venous phase (VP) were performed with low dose spectral CT mode. VNE images were generated from AP (VNEA) and VP(VNEP) spectral CT images. 2 board-certified radiologists reviewed both TNE and VNE images for image quality and lesion detection.Mean CT value, signal-noise-ratio (SNR) and contrast-noise-ratio (CNR) for liver, pancreas, spleen, kidney and muscle weremeasured. Lesion detection rate, subjective image rating and radiation dose were assessed and compared.

RESULTS

Both TNE and VNE images satisfied clinical needs for lesion detection and image quality. The image quality scores were 4.78±0.47,4.56±0.76 and 4.68±0.59 for TNE, VNEA and VNEP, respectively with no difference. There was no difference for the lesiondetection rate (number) with the plain CT scan (66.8% (135), 63.4% (128) and 65.8% (133), respectively) (p>0.05). CT number (inHU) in liver, pancreas, spleen, kidney and muscle were, respectively, (52.00±7.38, 34.00±6.41, 46.35±5.59, 30.03±4.48 and45.56±7.80) on TNE, (53.01±6.13, 35.99±6.73, 49.74±5.74, 31.91±3.86 and 44.22±7.10) on VNEA and (56.17±5.87, 36.60±7.12,50.94±4.55, 32.61±3.66, and 46.03±6.92) on VNEP. There was slight bias for CT numbers on VNE. However, the absolute CTnumber difference between VNE and TNE was less than 5HU, with the largest at VP for the spleen. VNEA had better CT numberfidelity with the smallest difference for the liver. CNR values in 3 groups were similar. VNE images provided statistically higher SNR.The potential dose reduction for replacing TNE with VNE was 30.12%.

CONCLUSION

VNE image generated from the contrast-enhanced abdominal low dose spectral CT provides adequate image quality for lesiondepiction, high CT number fidelity and 30% dose reduction compared with TNE.


VNE images generated from the contrast-enhanced abdominal spectral CT may be used to replace TNE images to provide adequateimage quality for lesion depiction and 30% dose reduction.

ParticipantsMaoqing Hu, Guangzhou, China (Abstract Co-Author) Nothing to DiscloseZaiyi Liu, Guangzhou, China (Presenter) Nothing to DiscloseChang Hong Liang, MD, Guangzhou, China (Abstract Co-Author) Nothing to DiscloseXiao Mei Lu, MMed, Shenyang, China (Abstract Co-Author) Nothing to Disclose

PURPOSE

To investigate the enhanced effects of abdominal vessels and liver parenchyma and the image quality in abdominal dynamic CT

SSJ08-03 Objective Image Quality and Detectability of Simulated Low-Contrast, Low-Attenuation (LCLA) LiverLesions on CT without and with an Integrated Circuit (IC) Detector and Iterative Reconstruction(IR): Effect of Radiation Exposure and Subject Size


SSJ08-04 The Use of Low Tube Voltage and ASIR Reconstruction to Improve Image Quality of CT Angiographyfor Tumor Blood Supply Arteries Under Low Concentration Contrast Condition


scans using different tube voltages and different concentrations of contrast agents at identical iodine delivery rate.


Six minipigs underwent repeated upper abdominal dynamic enhanced CT scans(256-slice CT scanner) under 4 protocols: group A(270 mgI/mL, 80kVp + iterative reconstruction (IR, iDose4) algorithm), group B (370 mgI/ml, 80kVp + IR algorithm), group C (270mgI/mL, 120kVp + FBP algorithm), group D (370 mgI/mL, 120kVp + FBP algorithm). The total iodine dose (600 mg I/kg) and iodinedelivery rate (0.92 mg I/s) of injected contrast agents were the same in all groups. The enhanced attenuations of abdominal aorta,portal vein and liver parenchyma were measured and the image noise, SNR and CNR in peak enhancement of liver parenchyma weredetermined. The subjective image quality was evaluated by two radiologists.

RESULTS

There were no significant differences in peak enhanced attenuations of abdominal aorta, portal vein and liver parenchyma between80kVp groups or 120kVp groups respectively (all P >0.05), the attenuations of vessels in 80kVp were significantly higher than in120kVp (all P <0.05). There were no significant differences in image noise, SNR and CNR of liver parenchyma between groups (all P>0.05). The subjective image quality scores were no significant difference.

CONCLUSION

Different concentrations of iodinated contrast agents given an injection protocol with the same iodine delivery rate and total iodinedose achieved the same enhancement of the abdominal vessels and liver parenchyma, 80 kVp with IR (iDose4) algorithm acquiredacceptable image quality.


The injection protocols and bolus characteristics of iodinated contrast agent should be optimized to achieve best enhancement andreduce radiation dose meanwhile.

ParticipantsAjit H. Goenka, MD, Cleveland, OH (Presenter) Institutional Research Grant, Siemens AGBrian R. Herts, MD, Cleveland, OH (Abstract Co-Author) Research Grant, Siemens AGFrank Dong, PhD, Solon, OH (Abstract Co-Author) Equipment support, Siemens AG Software support, Siemens AGNancy A. Obuchowski, PhD, Cleveland, OH (Abstract Co-Author) Research Consultant, Siemens AG Research Consultant, Hologic,Inc Research Consultant, Cardiovascular Ultrasound Services, Inc Research Consultant, Elucid Bioimaging IncAndrew Primak, PhD, Malvern, PA (Abstract Co-Author) Employee, Siemens AGWadih Karim, RT, Cleveland, OH (Abstract Co-Author) Nothing to DiscloseMark E. Baker, MD, Cleveland, OH (Abstract Co-Author) Research Consultant, Bracco Group; Researcher, Siemens AG; Researchsupport, Siemens AG

PURPOSE

To assess image quality and LCLA liver lesion detection in semi-anthropomorphic phantom using either discrete circuit (DC) detectorand FBP or IC detector and IR at varied radiation exposures and phantom diameters


A phantom without and with 5-cm thick fat-mimicking ring (30- and 40-cm diameters) and containing liver inserts with 4 sphericallesions was scanned with 5 exposure settings [30-cm phantom:200 (CTDIvol 13.5 mGy), 150, 100, 50, and 25 eff mAs; 40-cmphantom:400 (CTDIvol 26.9 mGy), 300, 200, 100, and 50 eff mAs] on two CT scanners, one equipped with DC and other with ICdetector. Images were reconstructed with FBP and IR (SAFIRE;S3) respectively. Image noise and lesion CNR were averaged at eachmAs. Four radiologists evaluated lesion presence on a 5-point diagnostic confidence scale. Data analyses included ROC curveanalysis, and noninferiority analysis (margin -0.10)

RESULTS

Image noise was significantly lower with IC-IR than with DC-FBP (P < .001) with greater reduction in 40-cm phantom and at lowerexposures. Lesion CNR was significantly higher with IC-IR than with DC-FBP (P < .001). When compared to DC-FBP at highestexposures, mean reader accuracy with IC-IR was noninferior up to 50% (100 eff mAs) and 25% (300 eff mAs) exposure reductionsfor 30- and 40-cm phantoms respectively (adjusted P < .001 and P = .04). IC-IR improved readers' confidence in presence of alesion (average difference 0.17 points) (P = .029) independent of phantom size or exposure level. At any given exposure level,however, there was no significant difference between mean AUCs with IC-IR and DC-FBP for either of 2 phantoms.

CONCLUSION

Moderate exposure reductions maintained non-inferior diagnostic accuracy for both detector-reconstruction combinations. Lesiondetection in 40-cm phantom was inferior at smaller exposure reduction than in 30-cm phantom. IC-IR improved objective imagequality and lesion detection confidence but did not result in superior diagnostic accuracy


Impact of noise-reduction on threshold radiation exposure below which diagnostic information may be lost depends on thecombination of patient size and imaging task. LCLA lesion detectability in simulated patients with larger girths is more sensitive toincreased noise at reduced radiation exposures than in simulated smaller patients. Task-specific measures are critical in determiningthe clinical utility of newer noise-reduction technologies.

SSJ08-05 Comparison of Attenuation Based Automated versus Empirical Method for Tube Voltage Selection inAbdominal-pelvic CT Examinations


ParticipantsLi Ye, Dalian, China (Presenter) Nothing to DiscloseAilian Liu, MD, Dalian, China (Abstract Co-Author) Nothing to DiscloseShifeng Tian, Dalian, China (Abstract Co-Author) Nothing to DiscloseYijun Liu, Dalian, China (Abstract Co-Author) Nothing to DiscloseJinghong Liu, MD, PhD, Dalian, China (Abstract Co-Author) Nothing to DiscloseTing Zhang, Da Lian, China (Abstract Co-Author) Nothing to Disclose

PURPOSE

To investigate the use of low tube voltage and adaptive statistical iterative reconstruction (ASIR) algorithm to improve imagequality and diagnostic confidence for tumor blood arteries under low contrast medium concentration.


Fifty-eight patients (boby mass index (BMI) ≤ 22 kg/m2) with suspected gastrointestinal tract malignant tumors CT scans wererandomly divided into two groups. Group A (21 men and 11 women, ages 40-90 years) was scanned with 80kVp and lowconcentration of contrast medium (270mgI/ml) and reconstructed with 50% ASIR. Group B (22 men and 4 female, ages 40-76years) underwent scanning with conventional 120 kVp and high concentration of contrast medium (350 mgI/ml). CT value andstandard deviation (SD) of the tumor blood supplying artery and fat in anterior abdominal wall were measured, and contrast-to-noise ratio (CNR) and value were calculated. Image quality was evaluated by two radiologists using a 5-point rating scale. Theinter-observer agreement was estimated by using weighted kappa statistics and Intra-class correlation coefficients (ICC) test.Image quality scores were compared by the Mann-Whitney U test. The paired Student t tests was used to compare the differencein CT value, SD value, CNR and CT dose index (CTDIvol) value between group A and B.

RESULTS

There was no difference in sex, age, BMI between two groups. The subjective image quality score of tumor blood supplying arteriesof group A was better than that of group B (4.7 Vs. 4.3) with very good inter-observer agreement (Kappa value>0.80; ICCvalue>0.75). The CT value and CNR of group A (458.85±69.03 HU and 20.20±3.30) were higher than those of group B(249.76±41.51HU and 9.31±1.89) (all P<0.001). The CTDIvol of group A (5.24±1.15 mGy) was lower than that of group B(13.47±4.73 mGy) (P<0.001).

CONCLUSION

For patients with BMI ≤22 kg/m2, the low tube voltage and low contrast medium concentration scanning with 50% ASiR algorithmcan reduce radiation dose and contrast medium concentration without sacrificing image quality.


Low tube voltage with 50% ASiR algorithm may be used for CT angiography of slim patients with adequate image quality todramatically reduce radiation and contrast dose.

ParticipantsFaezeh Sodagari, MD, Chicago, IL (Presenter) Grant, Siemens AGAdeel R. Seyal, MD, Chicago, IL (Abstract Co-Author) Grant, Siemens AGAtilla Arslanoglu, MD, Chicago, IL (Abstract Co-Author) Grant, Siemens AGCecil G. Wood III, MD, Chicago, IL (Abstract Co-Author) Nothing to DiscloseVahid Yaghmai, MD, Chicago, IL (Abstract Co-Author) Nothing to Disclose

PURPOSE

To compare the performance of attenuation based automated tube voltage (kV) selection software with known empirical method forkV selection in abdominal-pelvic CT examinations.


The study was HIPAA compliant and IRB approved. Eighty patients who underwent abdominopelvic CT examinations were included inthe study. All patients were scanned on the same CT scanner using automated kV selection. Lateral-width of the patient wasdetermined. and patients were grouped based on their lateral-widths. Each lateral width group corresponded to an optimal kV(lateral-width based kV selection). Comparison was made between the kV selected using the automated selection software and theoptimal kV based on lateral-widths.

RESULTS

Attenuation based automated kV selection resulted in a lower optimal tube potential in 32 out of 80 (40%) patients when comparedwith kV selection based on patient lateral-width (P<0.0001). None of the patients were scanned with a higher kV using automatedselection. Agreement between the two methods of kV selection was fair (κ-coefficient=0.28, 95% CI: 0.15 - 0.41).

CONCLUSION

Attenuation based automated tube voltage selection may be a more effective method for radiation dose reduction when comparedto tube voltage selection based on patient width.


Attenuation-based automated tube voltage selection allows greater reduction in radiation dose compared to empirical methods.

Honored Educators

Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying

SSJ08-06 Application of kV Assist Associated with Adaptive Statistical Iterative Reconstruction (ASiR) inReducing Radiation Dose of Hepatic Enhanced CT Scan


educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-qualityeducational content in their field of study. Learn how you can become an honored educator by visiting the website at:https://www.rsna.org/Honored-Educator-Award/

Vahid Yaghmai, MD - 2012 Honored EducatorVahid Yaghmai, MD - 2015 Honored Educator

ParticipantsQingguo Wang, Shanghai, China (Presenter) Nothing to Disclose

PURPOSE

To evaluate the impact of kV assist associated with ASiR on dose and image quality in hepatic enhanced CT scan.


This study included 46 patients who underwent CT angiography for upper abdomen using a 64-row CT scanner (GE Discovery CT750HD). Patients were divided into two groups using kV assist technique.Group A (n=23,BMI: 20.72±2.37) and group B (n=23, BMI:22.31±1.82) underwent CT scan with 120kVpand low tubekVp (≤100kVp), respectively.Data of group B were reconstructedwith afixed blending level (50% and 0% respectively) of ASiR for each image set. The baseline was 120 kVp, noise index (NI)=12.0(5mm).The CT values of abdominal fat layer, aorta (AR) andliver were measured.Thecontrast noise ratio (CNR) of AR and SMA werecalculated respectively. The CT dose index volume (CTDIvol) of each patient were recorded. The dose length produce (DLP) wasrecorded and effective radiation dose was calculated.

RESULTS

The mean CTDIvol and effective radiation dose in group B (6.06 ±2.80mGy, 2.31 ±1.06mSv) were significantly lower than group A(9.26±4.69mGy, 3.81 ±2.31mSv) (p<0.05). The mean CT value of liver in group A(70.33±8.09Hu)wasnot significantlydifferentwiththat ingroup B (0% ASiR) (73.82±10.83Hu) andgroupB(50% ASiR)( 73.94±10.80Hu) (each p>0.05), respectively.The SD value ofsubcutaneous fat in group A (8.17±1.49HU) was lower than group B(50% ASiR) (9.57±1.59HU) (p<0.05). The CNR of liver(16.64±3.66)in group B (50% ASiR) was not significantlydifferentwith that in group A (18.99±3.75)(p>0.05). The SNRs of liver ingroup B (50% ASiR) (9.33±2.07) were higher than in group A (7.57±1.61) (p<0.05).

CONCLUSION

KV assist recommended optimal scan protocol,andapproximately39% radiation dosewasreduced without degradation of imagequality.


KV assist helps to improve patient care through personalized protocols and simplify scan technique optimization.

SSJ12-01 Health Service, Policy and Research Keynote Speaker: Assessing Individual Performance in Radiology

Tuesday, Dec. 1 3:00PM - 3:10PM Location: S102D

SSJ12-02 Framing Bias Effects on Retrospective Reviews of Radiological Reports


SSJ12-03 Performance Testing for Radiologists Interpreting Chest Radiographs


SSJ12

ISP: Health Service, Policy and Research (Quality)


HP SQ RS



ParticipantsJonathan James, BMBS, Nottingham, United Kingdom (Moderator) Nothing to DiscloseEdward Y. Lee, MD, MPH, Boston, MA (Moderator) Nothing to Disclose

Sub-Events

ParticipantsJonathan James, BMBS, Nottingham, United Kingdom (Presenter) Nothing to Disclose

ParticipantsJeffrey D. Robinson, MD, MBA, Seattle, WA (Presenter) Consultant, HealthHelp, LLC; President, Clear Review, Inc; Daniel S. Hippe, MS, Seattle, WA (Abstract Co-Author) Research Grant, Koninklijke Philips NV; Research Grant, General ElectricCompany

PURPOSE

When reviewing difficult exams, radiologists often disagree on the severity of a potential error. In the legal setting, this is oftenattributed to retrospective or framing bias. This study examines the effect of framing bias on radiologists' perceptions whenevaluating potential errors.


This study was IRB approved. Eleven de-identified exams that had been subject of malpractice litigation and four uncontestedcontrol exams were divided into four review sets each containing three litigation (L) exams and one control (C) and theiraccompanying reports. Volunteers solicited from the ACR directory were randomly assigned to one of four groups (P,D,Q,N). Group Pwas told that they had been retained by a malpractice plaintiff's attorney; D that they had been retained by a defense attorney; Qthat a neighboring hospital requested an outside QA review and N was given no context. Subjects were also randomly assigned toone of the four review sets, and asked for each exam if the radiology report failed to meet the standard of care (failure). The ratesat which each group judged each type of exam to be a failure were compared using a multivariate, mixed-effect, logistic regressionmodel.

RESULTS

The study was completed by 102 radiologists, yielding 368 reviews (276 L, 92 C).Together, all four groups rated L exams as failuresin 57% of assessments, and C exams in 27% (p= 0.006).The difference in ratings between L and C exams was most pronounced inGroup P(62% vs. 26%, p=0.013) and Group N(66% vs. 18%, p=0.003). Within the subgroup of L exams,Group P was significantlymore likely to judge an exam a failure than the Group D(62% vs 48%, p= 0.032). The Q and N groups were not significantly differentthan the other groups.

CONCLUSION

Framing bias plays a significant role in retrospective review. Told that the exams they were reviewing were problematic, reviewersrated 27% of control exams below the standard of care. Simulated plaintiff's experts rated litigation exams below the standard ofcare significantly more frequently that simulated defense experts rated the same exams. These differences in performance highlightthe effect such bias plays in actual expert witness review.


Since framing bias can significantly affect reviewers' impressions, blinding a reviewer to the nature of the exam being reviewedshould increase the objectivity of the reviewer's judgment.

ParticipantsYan Chen, Loughborough, United Kingdom (Presenter) Nothing to DiscloseJonathan James, BMBS, Nottingham, United Kingdom (Abstract Co-Author) Nothing to DiscloseLeng Dong, Loughborough, United Kingdom (Abstract Co-Author) Nothing to DiscloseAlastair G. Gale, PhD, Loughborough, United Kingdom (Abstract Co-Author) Nothing to Disclose

PURPOSE

The aim was to develop a system to assess the image interpretation performance of radiologists in identifying signs of malignancy

SSJ12-04 Do Socioeconomic Disparities Exist in Radiology? Multivariate Analysis of Socioeconomic FactorsImpacting Access to Imaging Services


SSJ12-05 Prevalence of Unanticipated Events Associated with MRI Examinations: A Benchmark for MRI Quality,Safety, and Patient Experience

on chest radiographs.


A test set of 30 digital chest radiographs was chosen by an experienced radiologist consisting of 11 normal and 19 challengingabnormal cases. The abnormal cases all had biopsy proven pathology; the normal cases had at least 2 years of imaging follow up.14 radiologists with a range of experiences were recruited. Participants individually read the test set displayed on a standardreporting workstation, with their findings entered directly onto a laptop running specially designed reporting software. For eachcase they were given the relevant clinical information and were asked to mark any perceived abnormality and rate their level ofsuspicion on a 5-points scale (normal, benign, indeterminate, suspicious or malignant). On completion of the test, participants weregiven instant feedback and had the opportunity to review cases were there was disagreement with the expert opinion andpathology. The time taken for the participants to complete the test was recorded.Differences between the participants'performance were assessed using ROC analysis.

RESULTS

The experience of the participants in reporting chest radiographs ranged from 1 to 26 years (Mean=9 yrs, Mdn=5 yrs). Participants'performance (ROC score) varied significantly between 2 groups (6 post-fellowship consultants, and 8 radiology residents). Radiologyresidents' performance as measured by ROC score was significantly poorer compared to post-fellowship consultants (Mean-RS=0.76, Mean-PFC=0.93, p=.003). There was a positive correlation between image interpretation performance (ROCMean=0.85,SD=0.11) and years of reading experience (Mean=9, SD=8.58) , r=.573, p=<.05, n=14.There was a trend for radiology residents totake longer to complete the task (Mean=26.51s) compared to post-fellowship consultant radiologists (Mean=19.65s), but this didnot quite reach statistical significance (p=.07).

CONCLUSION

This pilot study demonstrates that it is possible to devise a method for performance testing the reporting of chest radiographs.


Chest radiographs are the first line imaging test for patients with chest symptoms suspicious of malignancy, this pilot studydemonstrates that it is possible to devise methods to test performance of the reporting radiologist.

ParticipantsOmid Khalilzadeh, MD, MPH, Boston, MA (Abstract Co-Author) Nothing to DiscloseAlvin Y. Yu, MD, Boston, MA (Abstract Co-Author) Nothing to DiscloseEmmanuel Carrodeguas, BS, Boston, MA (Abstract Co-Author) Nothing to DiscloseAnand M. Prabhakar, MD, Somerville, MA (Abstract Co-Author) Nothing to DiscloseSynho Do, PhD, Boston, MA (Abstract Co-Author) Nothing to DiscloseGarry Choy, MD, MS, Boston, MA (Abstract Co-Author) Nothing to DiscloseJames A. Brink, MD, Boston, MA (Abstract Co-Author) Nothing to DiscloseEfren J. Flores, MD, Boston, MA (Presenter) Nothing to Disclose

PURPOSE

Racial disparities are known to exist in medicine, but little has been studied in radiology. One way to examine this is to look atmissed radiology appointments or missed care opportunities (MCO) which result in delayed diagnoses and negatively impact patientcare. Moreover, MCO in radiology may be a symptom of missed appointments in other specialties. The reason for missingappointments is multifactorial, and socioeconomic factors may play an important role. In this study, we investigated thedemographic factors associated with radiology missed appointments.


Demographic data of 975,539 ordered radiologic imaging exams at our institution in the calendar year 2014 was collected. Thedataset included: ethnicity/race, primary language, insurance status, and reasons for cancellation of the appointment. Theassociation of different factors with radiology MCOs was evaluated. Multivariate logistic regression models were implemented toevaluate the independent relationship between radiology MCOs and various factors.

RESULTS

MCO was the most common reason for not completing a radiologic exam (41.5%). Overall, there was about 5% MCO (42,854) inradiology appointments during the calendar year 2014. A primary language other than English (OR: 1.2), Black ethnicity (OR: 1.8,relative to White) and Hispanic ethnicity (OR: 1.5, relative to White) were significantly associated with higher odds of MCO on aradiology appointment. Among different scan type, the odds of MCO was significantly higher for CT angiograms (OR: 2.8, P<0.001).These associations remained significant after multiple adjustments for potential confounding variables.

CONCLUSION

There was a high number (42,854) of radiology MCO in the past year at our institution. Non-English primary language and Hispanicethnicity significantly correlate with likelihood of missing a radiology appointment. Our results identify patients who are at risk forMCO and provide opportunities for intervention that will improve the patient's experience and address healthcare disparities.Possible interventions to bridge the gap include telephone reminders in the patient's native language, scheduling radiologyprocedures with radiologists that come from similar background, assistance in coordination of transportation, among others.


Socioeconomic disparities exist in radiology. Further research in this area is paramount to examine the impact to healthcare access.


SSJ12-06 Technologist-directed Radiograph Repeats: Frequency and Associations


AwardsTrainee Research Prize - Resident

ParticipantsGelareh Sadigh, MD, Atlanta, GA (Presenter) Nothing to DiscloseAmit M. Saindane, MD, Atlanta, GA (Abstract Co-Author) Nothing to DiscloseKimberly E. Applegate, MD, MS, Zionsville, IN (Abstract Co-Author) Nothing to Disclose

PURPOSE

To determine the prevalence of unanticipated events (UE) associated with MRI examinations in a multi-center academic radiologydepartment.


UE reported by MRI technologists for examinations performed between June 2013 and November 2014 on 17 scanners in auniversity- (UH) and community-affiliated (CH) hospitals of single health system were retrospectively reviewed. Events werecategorized into: (1) orders and scheduling (no/improper order, insurance problem, scheduled wrong study/location, schedulingscreening failure, improper preparation instruction/study protocol); (2) delays in scan (late patient arrival/transport,anesthesia/pathology procedure delays, delays in getting correct protocol or checking images); (3) foreign bodies (unanticipatedmetal/foreign body/pacemaker); (4) non-contrast related (NONCON) patient events (claustrophobia, patient discomfort, bodyhabitus, pregnancy, nausea, pain, motion, need for sedation/general anesthesia, inability to complete the exam, patientdissatisfaction, patient fall, code called for resuscitation); (5) contrast related (CON) patient events (reaction, extravasation, lackof IV access, patient refusal of contrast); (6) technical acquisition issues (fat saturation, breath-holding, contrast bolus timing,mechanical scanner failure). Each category was compared between scanners located in UH vs. CH, and scanners that are solelyused for outpatient services (OP) vs. those used for outpatients and inpatients (OP/IP).

RESULTS

34,587 MRI examinations were assessed (87% UH; 59% OP) with 5,760 (17%) UE; (1.9% of patients had more than one categoryevents). Rates of UE for each category were as follows: 1.8% orders and scheduling [0.06% patient arriving wrong day, and 0.03%patient call-back], 3.3% delays in scan, 0.5% foreign bodies, 10.4% NONCON events, 1.3% CON events, and 1.5% technical issues.Most frequent patient issues were motion, claustrophobia, and need for sedation. UH exams had higher reported rate of UE. OPexams had higher rates of orders and scheduling problems and delays in scans, while OP/IP exams had more patient related andtechnical issues (all P<0.05).

CONCLUSION

UE associated with MRI exams are common (17%), with the majority being patient related issues.


Unanticipated patient events are common. Awareness of the prevalence and types of unanticipated events by MRI staff providesopportunities for practice improvement.

ParticipantsJill E. Jacobs, MD, New York, NY (Abstract Co-Author) Nothing to DiscloseAndrew B. Rosenkrantz, MD, New York, NY (Presenter) Nothing to DiscloseJoseph J. Sanger, MD, New York, NY (Abstract Co-Author) Nothing to DiscloseMarc Parente, New York, NY (Abstract Co-Author) Nothing to DiscloseDanny C. Kim, MD, White Plains, NY (Abstract Co-Author) Nothing to DiscloseMichael P. Recht, MD, New York, NY (Abstract Co-Author) Nothing to Disclose

PURPOSE

The decision to repeat a suboptimal radiograph by the technologist at the time of acquisition, prior to radiologist review, is aninfrequently assessed but potentially significant source of excess patient radiation. We assessed the technologist-directedradiograph retake rate in our hospital network.


We created an analysis tool to track all technologist-directed radiograph rejections for 52 CR and DR imaging device networks in 9of our hospital-based imaging centers. The tool captured all acquired images and the reject reason in a reject log file (RLF). All RLFswere downloaded monthly to an encrypted USB flash drive, renamed in standardized convention, and uploaded to a protectednetwork share drive. Information Technology staff reviewed all RLFs to ensure completeness and validity. RLFs were then importedinto a Reject Analysis Database. Analysis was performed for a 6 month period (6/1/14-11/30/14). Retake rate by case (RRC) wasnumber of retaken exposures (NR) acquired as a percentage of the total number of cases (TC) performed where RRC=(NR/TC)*100. Retake rate by exposure (RRE) was number of retaken exposures (NR) acquired as a percentage of the total numberof expected exposures (EE) for all performed examinations where RRE= (NR/EE)*100. Data was stratified by date, site, imagingdevice, body part, and reject reason.

RESULTS

Overall technologist-directed RRC and RRE were 3.4% and 1.8%, respectively. Body part RRC and RRE, respectively were: chest(5.9%, 4.4%); abdomen (3.3%, 1.6%); joint (3.0%, 1.3%); spine (2.6%, 1.2%); skull (1.8%, 1.0%); skeletal survey (1.6%, 0.8%),and unspecified (5.0%, 3.5%). For hospital portable devices, RRC was 9.2% overall (12.5% abdomen; 8.8% chest) and RRE was9.2% overall (10.8% abdomen and 9.0% chest). The most common reason for repeat exposures was positioning error (2.3% overall)for both portable and non-portable examinations.

CONCLUSION

Rates of technologist-directed radiograph retake vary by body part and are higher for portable examinations.


Technologist education to identify and correct sources of imaging error is necessary to reduce retake rates and decrease excesspatient radiation.

SSJ21-01 Novel Concept for Dose Reduction - Region-setting CT: Is Multileaf Collimator Also Valuable forDiagnostic CT?

Tuesday, Dec. 1 3:00PM - 3:10PM Location: S403A

SSJ21-02 Diagnostic Accuracy and Radiation Dose Reduction Achievable in Digital Subtraction Angiogram withElimination of Pre-contrast Images by Simultaneously Triggering X-ray and Contrast Injection


SSJ21

Physics (Radiation Dose Control II)


CT PH SQ


ParticipantsMichael F. McNitt-Gray, PhD, Los Angeles, CA (Moderator) Institutional research agreement, Siemens AG; Research support,Siemens AG; ; ; ; ; Dianna D. Cody, PhD, Houston, TX (Moderator) In-kind support, General Electric Company

Sub-Events

ParticipantsFumio Hashimoto, Toyoake, Japan (Presenter) Nothing to DiscloseAtsushi Teramoto, PhD, Toyoake, Japan (Abstract Co-Author) Nothing to DiscloseYasuki Asada, PhD, Toyoake, Japan (Abstract Co-Author) Nothing to DiscloseShouichi Suzuki, PhD, Toyoake, Japan (Abstract Co-Author) Nothing to DiscloseHiroshi Fujita, PhD, Gifu City, Japan (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

A region-setting CT system is a prototype of a diagnostic CT applying the conformal irradiation method, and can strongly reducethe radiation dose outside the ROI. However, there has been no reporting about physical implementation of this system. Therefore,we developed the prototype of a region-setting CT system using a multileaf collimator (MLC). The aim of this exhibit is to show thepossibility of our prototype CT for clinical use.The teaching points of this exhibit are:1.The image quality of the region-setting CT isequivalent to that of conventional CT.2. A region-setting CT cuts the radiation dose outside ROI by 70%.

TABLE OF CONTENTS/OUTLINE

1. The principle of a region-setting CT method2. Explanation of a region-setting CT system - Block diagram and appearance of theexperimental system - Procedure of scanning and image reconstruction algorithm3. Quantitative evaluation of acquired volumeimage4. Radiation dose - Conventional CT scan vs. a region-setting CT scan

PDF UPLOAD

http://abstract.rsna.org/uploads/2015/15017723/15017723_6eb1.pdf

ParticipantsKarunakaravel Karuppasamy, MBBS,FRCR, Westlake, OH (Presenter) Nothing to DiscloseBandar O. Safar, MD, Cleveland Heights, OH (Abstract Co-Author) Nothing to DiscloseRam Kishore R. Gurajala, MBBS, FRCR, Beachwood, NJ (Abstract Co-Author) Nothing to DiscloseKevin Wunderle, Broadview Heights, OH (Abstract Co-Author) Nothing to DiscloseMaria del Pilar Bayona Molano, MD, Brecksville, OH (Abstract Co-Author) Nothing to DiscloseAmanjit S. Gill, MD, Cleveland, OH (Abstract Co-Author) Nothing to DiscloseMark J. Sands, MD, Cleveland, OH (Abstract Co-Author) Nothing to DiscloseRandolph M. Setser, DSc, PhD, Cleveland, OH (Abstract Co-Author) Employee, Siemens AG

PURPOSE

To assess the feasibility, measure diagnostic accuracy and estimate radiation dose reduction by using the first post-contrast imageas a mask in digital subtraction angiogram (DSA) compared to conventional DSA that uses a pre-contrast image as mask.


In this retrospective study, 30 consecutive patients (18 male, 12 female) who had cavogram during IVC filter placement wereincluded (24-iodinated contrast, 6- CO2). In the control group, conventional DSA runs were automatically generated using a pre-contrast image as the mask. In the experimental group, from the same DSA runs, pre-contrast images were removed and by re-masking, the first post-contrast image was assigned as the new mask. In the control group, total number of images, number of pre-contrast images and radiation dose per run were recorded. IVC signal to noise (SNR) was measured in both groups. Followingmetrics were collected independently by two radiologists: Image quality (scale of 1 to 5; not acceptable to excellent subtractedimages), diagnostic confidence (scale of 1 to 5; thrombus is definitely present to definitely absent) and suitability for IVC filterplacement (scale of 1 to 4; suitability cannot be determined to suitable for infra-renal filter). Paired t-test was used for analysis.

RESULTS

In the control group, 23 images per run were obtained (SD 6, range 10-33). Kerma area product and reference point air kerma perrun were 2371 µGym2 (SD 1486, range 306-6273) and 86 mGy (SD 53, range 12-241) respectively. On an average, 7 pre-contrastimages were acquired per run (SD 2, range 1-11) and this estimates to 32% (SD 9%) radiation dose. SNR (mean 32.9 vs. 32.5,p=0.87), image quality (mean 3.95 vs 3.85, p=0.33), diagnostic confidence (mean 4.78 vs 4.81, p=0.48) and suitability for IVC filter

SSJ21-03 Effect of Cardiac Phase-Based Tube Current Modulation on Dose Efficiency in a Clinical CT Scanner


SSJ21-04 The Effect of KV Assist on Radiation Dose Reduction and Image Quality for Abdominal CT in DifferentBMI Groups


placement (mean 3.68 vs. 3.85; p=0.11) were similar between the groups.

CONCLUSION

Elimination of pre-contrast images by simultaneously triggering x-ray and contrast injection and using first post-contrast image asmask achieves significant radiation dose reduction with preserved SNR and diagnostic accuracy in selected DSA.


It is common practice to obtain pre-contrast images and this adds significantly to overall radiation dose in DSA. In our study, theearliest post-contrast image contained very little contrast near the tip of the catheter and did not impact on the diagnosticusefulness when used as a mask to generate DSA run.

ParticipantsAdam Budde, MS, Madison, WI (Presenter) Employee, General Electric CompanyKriti Sen Sharma, PhD,BEng, Woburn, MA (Abstract Co-Author) Employee, General Electric CompanyBrian E. Nett, PhD, Waukesha, WI (Abstract Co-Author) Employee, General Electric Company

PURPOSE

A novel method for improving dose efficiency in cardiac scans has been developed and implemented on a clinical CT scanner. Themethod modulates the tube current based on knowledge of the weighting function applied to sinogram data in half-scanreconstructions. We assess the image quality and dose efficiency of this method on a wide-cone CT scanner (Revolution CT, GEHealthcare).


Phase-based tube current modulation improves dose efficiency by delivering reduced dose to views that are down-weighted duringthe reconstruction process. A comparison of this method and the clinical baseline, a constant mA protocol, was performed on a 20cm water phantom. Since the modulation adjusts based on the amount of phase padding prescribed by the user, a furthercomparison was performed across clinically-used paddings. Image noise at the center of the phantom was measured through regionof interest measurements of image pixel variance. 2D noise power spectrums were also measured and, to quantitatively assessnoise isotropy, an NPS radial symmetry metric was calculated as the (max-min)/max of the tangential average of the 2D NPS. Allscans used cardiac reconstructions with a gantry rotation period of 280 ms and had equal dose, as determined by the integral ofthe mA.

RESULTS

Using 50 ms phase padding, the equal dose mA modulation reduced the image variance by 29.3% at the center reconstructedphase, 26.7% at the reconstructed phases 25 ms from center, and by 12.9% at the reconstructed phases 50 ms from center.When phase padding was reduced from 50 ms to 0 ms, the image variance at the center reconstructed phase showed an improvedreduction of 36.8% from the constant mA value. The NPS radial symmetry metric of the center recons was consistent going fromconstant mA to the 50 ms phase padding modulation case (0.43 to 0.44), but improved on the 0 ms phase padding case (0.31),indicating some noise isotropy improvement.

CONCLUSION

Phase-based dose modulation improves dose efficiency in cardiac scans on a clinical CT scanner.


Radiation dose reduction is achieved on cardiac scans of a clinical CT scanner without compromising image noise levels throughphase-based tube current modulation.

ParticipantsPing Hou, MD, Zhengzhou, China (Presenter) Nothing to DiscloseXiang-Nan Feng, MS, Hong Kong, Hong Kong (Abstract Co-Author) Nothing to DiscloseJianbo Gao, MD, Zhengzhou, China (Abstract Co-Author) Nothing to DiscloseJie Liu, Zhengzhou, China (Abstract Co-Author) Nothing to DiscloseYaojun Jiang, MD, Zhengzhou, China (Abstract Co-Author) Nothing to Disclose

PURPOSE

To evaluate the effect of KV Assist on radiation dose reduction and image quality for abdominal CT in different BMI groups


100 patients underwent abdominal CT on a new generation spectral CT scanner(Discovery CT, GE healthcare). The patients weredivided into 2 groups for prospective analysis. Group A(n=50) used KV assist protocol, which automatically selects an optimal kVpbased on the scout view. While the conventional 120kVp scan using auto mA protocol was performed on Group B(n = 50). The mainparameters of protocol were setup with noise index of 10, auto mA ranges at 100-450mA and rotation time at 0.8s. Group A and Bwere both further divided into two subgroups according to BMI(BMI <24 kg/m2for group A1/B1 and BMI≥24 kg/m2 for groupA2/B2).CT values and SD values, CNR of CA, PV, liver, pancreas and image quality score in abdomen were measured and calculated.CTDIvol and DLP of each patient was recorded and compared. Comparison between group A and B was implemented as arepresentative of those for the subgroups. The data were analyzed using Rand-sum test and t test.

RESULTS

Image noise of protocol A and B in dual-phase were(10.70±2.65),(8.83±2.38) HU and (11.27±3.82),(8.82±2.25) HU, respectively.

SSJ21-05 Optimization of Soft-Tissue Imaging in CT with the Aid of Additional Tin Filtration


SSJ21-06 Has the Radiation Dose of the X-ray Equipment Currently Used for Cardiac Intervention ProceduresBeen Reduced? A Longitudinal and Cross-sectional Study


Image noise of protocol A and B in dual-phase were(10.70±2.65),(8.83±2.38) HU and (11.27±3.82),(8.82±2.25) HU, respectively.However, CNR values obtained in group A vs in group B were comparable or higher in both LAP(19.99±9.98 vs 18.64±6.29 in CA,p>0.05; 1.13±1.13 vs 1.13±1.25 in liver, p>0.05; and 3.38±1.64 vs 2.64±1.42 in pancreas, p<0.05) and PVP(8.61±3.03 vs7.60±2.88 in PV, p>0.05; 4.30±1.67 vs 3.92±1.65 in liver, p>0.05; and 2.91±1.46 vs 2.25±1.45 in pancreas, p<0.05). Besides, thedifference of the subjective rating scores in protocol A and B were statistically insignificant(p=0.554). Effective dose in group Awas significantly lower than that in group B (4.6±2.4mSv vs 6.6±3.1mSv, p=0.02) and was decreased by 30.31%. Percentages of80kVp, 100kVp, 120kVp and 140kVp scans using KV assist were 31%, 58%, 11% and 0% for group A1, while 0%, 0%, 35%, and65% for group A2. The radiation dose reduction in group A1 and A2 were 30.18% and 22.71% compared with group B1 and B2.

CONCLUSION

Abdominal enhanced CT scans using KV assist can provide better image quality and 30.31% radiation dose reduction. Radiation dosereduction on patients with BMI<24 kg/m2 was more than patients with BMI≥24 kg/m2.


KV assist allows low kVp scans automatically applied on patients with low to moderate BMI and provides good image quality withlower radiation dose.

ParticipantsMarcel L. Dijkshoorn, RT, Rotterdam, Netherlands (Presenter) Consultant, Siemens AGRonald Booij, RT, Rotterdam, Netherlands (Abstract Co-Author) Nothing to DiscloseMarcel Van Straten, PhD, Rotterdam, Netherlands (Abstract Co-Author) Research collaboration, Siemens AG

PURPOSE

To assess the dose reduction potential of an x-ray tube with additional tin (Sn) filtration in non-enhanced thoracic and abdominalCT.


Eight anthropomorphic thorax and abdomen phantoms varying from 10x15cm² to 30x40cm² (QRM, Germany) were scanned on a CTscanner (SOMATOM Force, Siemens) with 11 different beam qualities (70, 80,…, 150 kV, and 100Sn and 150Sn kV) at a fixed 32 cmCT dose index (CTDI) of 3mGy. Images were reconstructed with an iterative reconstruction algorithm (ADMIRE) at strength 0 and 3using soft tissue, bone and lung kernels. The contrast-to-noise ratio divided by the square root of the dose (CNRD) was used asthe parameter to be optimized. Contrast was assessed with the aid of tabulated mass attenuation coefficients. Noise was measuredin lung and liver equivalent tissue. Besides the reported CTDI, dose was measured with an ionization chamber in the centre andperiphery of the phantoms.

RESULTS

Image contrast was virtually independent of kV and therefore assumed to be constant over all scans. Measured dose relative to thereported CTDI value was approximately 2.5 times higher for the paediatric thorax phantoms at 70 kV. For higher voltages and largerphantom sizes, differences between measured and reported doses ultimately diminished. Optimal CNRD was found at 100Sn. Basedon the measured dose and averaged over all phantoms and kernels, the use of 100Sn resulted in a dose reduction of 22% (range7%-32%). For high resolution kernels in relatively large phantoms, dose reduction potential was less (up to a factor of two) or evenabsent. Dose reduction amount was independent of ADMIRE strength. Radiation output in terms of mGy/mAs was 11 times lower at100Sn than at 100 kV. This prohibits the use of 100Sn in large patients and relatively high dose studies. In general, the use of atube voltage without tin filtration was then the second best choice for the highest CNRD. The beam quality 150Sn was of use inthe largest abdomen phantom only.

CONCLUSION

Tin filtration at 100 kV results in the most optimal beam quality for the complete range of patient sizes. Due to tube limitations thismight not always be an option depending on the baseline reference dose of the scan protocol.


Best results of added tin filtration are to be expected in smaller sized patients and dedicated low dose soft tissue non-enhancedstudies such as screening and lung nodule follow-up.

ParticipantsYohei Inaba, PhD, Sendai, Japan (Presenter) Nothing to DiscloseKoichi Chida, PhD, Sendai, Japan (Abstract Co-Author) Nothing to DiscloseMasayuki Zuguchi, MD, Sendai, Japan (Abstract Co-Author) Nothing to Disclose

TEACHING POINTS

-To understand the importance of measuring/optimizing the radiation dose(cineangiography and fluoroscopy) of x-ray systems usedfor intervention procedure(IR). -To clearly the entrance doses of x-ray equipment used for IR today and in the past. -To clarify theimage quality of cineangiography and fluoroscopy of many IR equipment.

TABLE OF CONTENTS/OUTLINE

Radiation dose measurement in x-ray systems used for IR -The entrance doses with cineangiography and fluoroscopy weremeasured. -The entrance doses for many IR x-ray systems in 2014, 2007, and 2001 were compared. Image quality evaluation forcineangiography and fluoroscopy -The spatial resolution and low contrast detectability were quantified in many IR systems. -Relationship between image quality and radiation dose were investigated. SUMMARY: Even today, many case reports have

documented radiation injury resulting from IR. Therefore, the patient dose should be kept as low as reasonably achievable,especially in IR. Although today, the entrance doses of x-ray equipment used for IR tend to be lower than previously, someequipment has a high radiation dose. Adequate parameters, such as the dose mode and additional filters, are necessary. Inaddition, checking the image quality of IR x-ray systems is significant issue. It is important to optimize the radiation dose and imagequality.

PDF UPLOAD

http://abstract.rsna.org/uploads/2015/15009856/15009856_dsk2.pdf

SSJ22-01 Dose Optimization of a Novel Single-source Dual-energy CT Technique Using Split Filter Technique: InVitro Assessment of Low-contrast Detectability, Image Quality and Iodine Quantification


SSJ22-02 Whole-body Human Imaging with Photon-counting-based CT at Clinically Relevant Doses


SSJ22

Physics (CT V-New Development 2)


CT PH SQ



ParticipantsRebecca Fahrig, PhD, Palo Alto, CA (Moderator) Employee, Siemens AG; Stockholder, TibaRay, Inc; ;

Sub-Events

ParticipantsAndre Euler, MD, Basel, Switzerland (Presenter) Nothing to DiscloseAnna L. Falkowski, Basel, Switzerland (Abstract Co-Author) Nothing to DiscloseAnushri Parakh, MBBS,MD, Basel, Switzerland (Abstract Co-Author) Nothing to DiscloseSebastian Manneck, Basel, Switzerland (Abstract Co-Author) Nothing to DiscloseDavid Dashti, Basel, Switzerland (Abstract Co-Author) Nothing to DiscloseBernhard Krauss, PhD, Forchheim, Germany (Abstract Co-Author) Employee, Siemens AG; ; Zsolt Szucs-Farkas, MD, PhD, Berne, Switzerland (Abstract Co-Author) Nothing to DiscloseSebastian T. Schindera, MD, Basel, Switzerland (Abstract Co-Author) Research Grant, Siemens AG; Research Grant, Ulrich GmbH &Co KG; Research Grant, Bayer AG

PURPOSE

To optimize the radiation dose of a dual-energy technique on a single-source CT scanner using a split filter (TwinBeam Dual-Energy,Siemens) by assessing the low-contrast detectability, image quality and iodine quantification.


The study used two different phantoms: a custom liver phantom containing 45 low-contrast lesions, placed in a water containermimicking an intermediate-sized patient (diameter: 30 cm) and an abdominal dual-energy phantom (both QRM, Moehrendorf,Germany) with six different iodine concentrations (2.3, 4.5, 5.3, 8.3, 15.8 and 23.5 mgl/ml) and added fat ring (outer dimensions:35 cm x 25 cm). The phantoms were scanned on a single-source scanner (SOMATOM Edge, Siemens) with (A) single-energy modeat 120 kVp and 130 ref mAs, (B) dual-energy mode at AuSn120 kVp and 640 ref. mAs (default protocol of the manufacturer) and(C) with a dose-optimized dual-energy mode at AuSn120 kVp and 420 ref. mAs (dose-neutral to the single-energy mode). Lesiondetection was performed by three radiologists independently. Image noise, CNR and CTDIvol were assessed. Software provided bythe vendor was used for iodine quantification. Descriptive statistics and Fisher exact test were applied.

RESULTS

The CTDIvol measured 7.3, 10.3, and 6.7 mGy for protocol A, B and C, respectively. The image noise was 25% and 13% lower andthe CNR 31% and 14% higher with protocol B and C, respectively, compared with protocol A. There was no significant difference inlesion detection rate between the protocols (80%, 78.5%, 80.7% for protocol A, B and C, respectively (p=1.0)). The error ofmeasurement for the iodine quantification ranged for protocol B from 2.2 to 14.7% and for protocol C from 2.2 to 9.4%.

CONCLUSION

The phantom study revealed that the novel split filter technique allows dose-neutral dual-energy acquisition on a single-source CTscanner at similar image quality and diagnostic accuracy compared with single-energy while providing the added value of the dual-energy mode.


Since the split filter dual-energy technique on a single-source CT scanner benefits from the added information like virtual non-contrast, iodine quantification or stone characterization and the dose-neutral aspect, it can replace single-energy protocols inclinical routine.

ParticipantsCynthia H. McCollough, PhD, Rochester, MN (Presenter) Research Grant, Siemens AGShuai Leng, PhD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseRalf Gutjahr, Munich, Germany (Abstract Co-Author) Grant, Siemens AGZhicong Yu, Rochester, MN (Abstract Co-Author) Nothing to DiscloseZhoubo Li, Rochester, MN (Abstract Co-Author) Nothing to DiscloseAhmed Halaweish, PhD, Rochester, MN (Abstract Co-Author) Employee, Siemens AGSteven M. Jorgensen, Rochester, MN (Abstract Co-Author) Nothing to DiscloseErik L. Ritman, MD, PhD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseSteffen Kappler, Dipl Phys, Forchheim, Germany (Abstract Co-Author) Researcher, Siemens AG

PURPOSE

SSJ22-03 Compressed Sensing-Based Computed Tomography Perfusion Imaging: Preliminary Study


SSJ22-04 Dose or Noise Reduction for Dynamic CT Perfusion: 4D Adaptive Time-Intensity Profile Similarity(aTIPS) Bilateral Filters (BF)


The aim of this study was to evaluate and assess human anatomy (using cadaveric specimens) at clinically relevant dose rates ona prototype, whole-body, photon-counting-detector CT scanner.


A prototype, whole-body CT scanner (Siemens Healthcare, Forchheim, Germany) was installed in our laboratory. The system is builton a Definition Flash dual-source platform, where the "A" tube/detector subsystem uses a conventional energy integrating detector(EID) and the "B" tube/detector subsystem uses a photon-counting detector (PCD). Following biospecimen committee approval anda thorough physics performance evaluation (dose, spatial and low-contrast resolution, CT number accuracy, etc.), a series ofscans was performed on a fresh-frozen human cadaver (head and neck, chest, abdomen/pelvis and extremity scans), threecadaveric heads, a cadaveric arm, and a cadaveric leg at clinically relevant doses (140 kV, 200-220 mAs, 0.5 - 1 s rotation time).Images were acquired using two energy thresholds (25 and 65 keV), resulting in the generation of two threshold datasets and twoenergy bin datasets. Scans were repeated using the EID and identical scan parameters. The EID data were used for datacompletion to avoid truncation artifacts when the anatomy was outside the PCD field of view (27.5 cm). Side by side comparisonswere made between the EID and PCD images.

RESULTS

Phantom measurements of image and dose performance demonstrated equivalent image quality and dose between the two systems,with the exception of section sensitivity profile, which was better on the PCD due to the smaller detector pixel size (0.5 mm vs 0.6mm). PCD images of the cadaveric anatomy were judged to be equivalent to the EID images, with the exception of improved qualityin regard to beam hardening; the high energy [65,140 keV] PCD images demonstrated notably decreased beam hardening,particularly in the skull. Ring artifacts, which are common in PCD CT systems, were not present.

CONCLUSION

The evaluated prototype whole-body PCD CT system was capable of clinical levels of image quality at clinical dose rates.


The ability to perform whole-body CT scanning using photon-counting detector technology will facilitate clinical investigations ofthis new technology.

ParticipantsEsmaeil Enjilela, PhD, London, ON (Presenter) Nothing to DiscloseTing-Yim Lee, MSc, PhD, London, ON (Abstract Co-Author) Research Grant, General Electric Company Royalties, General ElectricCompanyJiang Hsieh, PhD, Waukesha, WI (Abstract Co-Author) Employee, General Electric CompanyKelley Branch, MD, Seattle, WA (Abstract Co-Author) Speakers Bureau, Pfizer IncRobb Glenny, Seattle, WA (Abstract Co-Author) Nothing to DiscloseAaron So, PhD, London, ON (Abstract Co-Author) Nothing to Disclose

Background

CT perfusion (CTP) of the heart comprised of dynamic scanning over time (~ 30 s) as injected contrast agent perfuses through themyocardium to allow for perfusion imaging based on modeled deconvolution. However, dynamic scanning can result in radiationdoses as high as 20 mSv. To reduce radiation dose, we developed a low x-ray dose CTP method for quantitative CT myocardialperfusion (MP) imaging from sparsely sampled low-intensity x-ray projections using a compressed sensing (CS) based algorithm. Thefeasibility of this approach for myocardial perfusion imaging was demonstrated in a pig. We performed prospective ECG-triggereddynamic CT imaging on a 70 kg farm pig at 140 kV and 80 mA/28 mAs (standard mA) using a GE Healthcare Discovery 750 HD CTscanner with contrast injection. The study was then repeated with the mA/mAs decreased to 20/7 (low mA). For standard mA, CTPimages were reconstructed from all (984) and from one-third (328) of available projections with filtered backprojection (FBP) andCS respectively. For low mA, CTP images were produced with one-half (492) of projections with CS reconstruction. Quantitative MPmaps from five consecutive 5 mm slices of the porcine heart were generated with CT Perfusion software (GE Healthcare). MPmeasurements from regions in the lateral free wall of the MP maps of these five slices and from ex-vivo gold standard microspheremeasurements were compared.

Evaluation

Compared with full view FBP MP maps, CS MP maps had biases of -0.01 (95% CI -0.05-0.03) and -0.05 (95% CI 0.16 - 0.07)mL/min/g, respectively, at standard and low mA. When CS MP maps were compared against ex-vivo microsphere MP measurements,the mean bias was found to be -0.12 (95% CI -0.26 - 0.03) and -0.15 (95% CI -0.04 -0.26) mL/min/g, respectively, at standardand low mA.

Discussion

Our study demonstrated that when sparsely sampled low-intensity x-ray projections are coupled with CS image reconstruction,quantitative MP maps with low bias can be generated with eight times lower radiation dose than that of our current technique.

Conclusion

The drastic reduction in radiation dose with our low-intensity sparse view scheme could facilitate the clinical use of CTP for MPimaging.

ParticipantsFrancesco Pisana, Heidelberg, Germany (Presenter) Doctoral student, Siemens AGThomas Henzler, MD, Mannheim, Germany (Abstract Co-Author) Nothing to Disclose

SSJ22-05 Impact of Selective Photon Shielding in Image Quality and Detectability Index for Unenhanced CT ofthe Chest: Study in a Five-year Old Anthropomorphic Phantom


SSJ22-06 Determining the Minimal Required Ultra Low Dose CT for Reliable Attenuation Correction of F-18 FDGPET-CT: A Phantom Study

Heinz-Peter Schlemmer, MD, Heidelberg, Germany (Abstract Co-Author) Nothing to DiscloseStefan O. Schoenberg, MD, PhD, Mannheim , Germany (Abstract Co-Author) Institutional research agreement, Siemens AGMarc Kachelriess, PhD, Heidelberg, Germany (Abstract Co-Author) Nothing to Disclose

PURPOSE

To significantly reduce image noise or patient radiation dose in dynamic perfusion CT imaging.


Due to the continuous x-ray exposure in CT perfusion, low values of tube current time product (e.g. 100 mAs) and tube voltagesettings (e.g. 70 kV) are desired to reduce dose. Noise increases considerably, potentially affecting quantitative perfusion values.Recently a time-intensity profile similarity (TIPS) 3D filter has been proposed for denoising of 4D perfusion CT data, weighing eachvoxel according to the distance from the central voxel, and to their time attenuation curves (TACs) similarity. In a first step wecreated a digital brain perfusion phantom, to individually optimize and compare TIPS 3D, multi band frequency (MBF) and runningaverage guided bilateral filters (RAGBF). After filter optimization, TIPS 3D showed better results compared to RAGBF and MBF interms of spatial noise reduction, while noise in temporal domain was still significant for all filters. In a second step TIPS 3D wasmodified adding an adaptive temporal width and a spatial bilateral guide (aTIPS-BF 4D). Simulated as well as measured patient datafrom a third generation dual source CT system were processed to validate our approach. Color maps were generated usingcommercially available software and compared with adaptive Gaussian filter (aGF).

RESULTS

aTIPS-BF 4D led to significant improvements in terms of ground truth TACs fidelity (sum of squared differences reduced by a factorof 1.8), and spatial resolution (FWHM of line spread function reduced by a factor of 1.4) when compared to TIPS 3D, while CNRimprovement factors were comparable (4.37 in aTIPS-BF 4D and 4.8 in TIPS 3D). aTIPS-BF 4D perfusion maps agreed with the onesobtained with aGF (average values y=1.0482x+0.0954 R²=0.9845, standard deviations y=1.0849x+0.1718 R²=0.8743) with theadditional benefit of a higher spatial resolution. This led to a higher detection of small ischemic regions in one stroke case and smallactive spots in a rectum tumor case.

CONCLUSION

4D aTIPS-BF significantly increases the CNR while preserving perfusion signal and spatial resolution.


The possibility to reduce image noise (or alternatively patient dose) when employing the aTIPS-BF filter would make quantitativedynamic CT perfusion more robust, potentially leading to a higher clinical acceptance in daily routine.

ParticipantsJuan Carlos Ramirez-Giraldo, PhD, Malvern, PA (Presenter) Employee, Siemens AGMarilyn J. Siegel, MD, Saint Louis, MO (Abstract Co-Author) Research Consultant, Siemens AG; Speakers Bureau, Siemens AGBernhard Schmidt, PhD, Forchheim, Germany (Abstract Co-Author) Employee, Siemens AG

PURPOSE

Evaluate the impact in image quality and detectability index (DI) of the use of selective photon shielding added to an x-ray tube inunenhanced CT of the chest using an anthropomorphic phantom.


A tissue-equivalent anthropomorphic five-year old phantom underwent a simulated nonenhanced CT examination of the chest usinga third-generation dual-source CT system using two protocols: (A) 100 kV and (B) 100 kV with a selective photon shield whichconsists of an additional piece of filtration (e.g. tin material) placed in between the x-ray beam and the patient. All scans used 196x 0.6 mm collimation, pitch = 1.2, and 0.5 s rotation time. Both scans used automatic exposure control, and were set to operate atthe same volume CT dose index of 0.6 mGy. Images were reconstructed with a sharp lung kernel at 3 mm thickness. For imagequality evaluation, standard measurements of noise and contrast-to-noise ratio (CNR) between air and soft tissue were calculated.Additionally, a more advanced task-based DI was calculated for a 10-mm diameter task with the purpose to simulate lung nodules.The DI is an image quality metric which incorporates into a single calculation the noise, noise power spectra, contrast-dependentspatial resolution, an eye filter, and task functions of varying contrast and size. All measurements were repeated five times. Paired-t tests were used for statistical comparisons.

RESULTS

Image noise decreased with protocol B relative to A (60.9 ± 3.3 HU vs 79.7 ± 9.0 HU, p < .01), representing a median reduction of23.0[22.0 - 23.2]%, while CNR between air and soft tissue increased with protocol B relative to A (13.4 ± 0.7 vs 10.3 ± 1.2, p <.01), representing a median increase in CNR of 30.7 [30.4-37.3]%. At the same time, the DI of tasks of 10mm diameter increasedwith protocol B relative to A (46.6 ± 1.5 vs 37.8 ± 0.9, p < .01), representing a median increase of DI of 20.1 [19.7-23.6]%.

CONCLUSION

At matched scanner output, the image quality of unenhanced CT of the chest is improved when using the selective photon shieldas demonstrated by standard metrics such as noise and CNR, while the detectability index of simulated lung nodules of 10 mm wasalso improved.


The results of this phantom study suggest that the addition of the selective photon shield improves image quality and thedetectability of relevant tasks such as lung nodules in pediatric unenhanced CT of the chest.


ParticipantsMing-Kai Chen, MD, PhD, New Haven, CT (Presenter) Nothing to DiscloseMonica Ghita, PhD, Richmond, VA (Abstract Co-Author) Nothing to DiscloseDavid W. Cheng, MD,PhD, New Haven, CT (Abstract Co-Author) Consultant, Bayer AG Consultant, Navidea Biopharmaceuticals, Inc

PURPOSE

To investigate minimal required sub mSv ultra low dose CT and corresponding tube current and voltage for reliable attenuationcorrection and semi-quantitation in FDG PET-CT in an effort for radiation dose reduction.

RESULTS

The minimal required ultra low dose of CT for precise quantification in all spheres (±10%) were determined by a combination of100kVp and 10mA for 0.5s, 0.2mGy measured CTDIvol and 0.31mSv estimated effective dose, or 80kVp and 20mA for 0.5s, 0.22mGyand 0.34mSv. Using the data, we could determine the CT parameters for reliable attenuation correction of PET with significantradiation dose reduction.

CONCLUSION

Our phantom study provided guidance in using ultra low dose CT for precise attenuation correction and semi-quantification of FDGPET imaging, which can further reduce CT dose and radiation exposure to patients in clinical PET-CT studies. The new iterativereconstruction algorithms available in CT should be further investigated to improve the image quality of the ultra low dose CTimages to provide also acceptable anatomical information in the PET-CT study.


Based on the data, we can further reduce the radiation dose to sub mSv using an ultra low dose CT for reliable attenuationcorrection in clinical FDG PET-CT studies.

SSJ24-01 Radiotherapeutic Managment of Hiadradenitis Suppurativa


SSJ24-02 Bone Metastases Treatment in A Rural Setting: The Effect of Choosing Wisely


SSJ24-03 Avoiding Skin Cream Application Right Before Radiation: Myth or Sound Advice?

SSJ24

Radiation Oncology (Outcomes/Quality of Life II)


RO SQ


ParticipantsDaniel W. Golden, MD, Chicago, IL (Moderator) Manager, RadOnc Questions LLCClifton D. Fuller, MD, PhD, Houston, TX (Moderator) In-kind support, General Electric Company; Research Grant, Elekta AB; ; ;

Sub-Events

ParticipantsMark G. Trombetta, MD, Pittsburgh, PA (Presenter) Nothing to DiscloseMichael W. Hall, MD, Pittsburgh, PA (Abstract Co-Author) Nothing to DiscloseE Day Werts, PhD, Pittsburgh, PA (Abstract Co-Author) Nothing to DiscloseJames Fontanesi, Bloomfield Hills, MI (Abstract Co-Author) Nothing to Disclose

ABSTRACT

Purpose/Objective(s): Hidradenitis Suppurativa (HS) is a chronic condition affecting the apocrine glands and their ducts which canbe debilitating and devastating for patients. Patient distress has resulted in chronic anxiety and even suicide in some patients.Standard therapy consists of, weight loss in obese patients, improved skin hygiene, antibiotics, and radical surgery. Radical surgerycan be debilitating and for patients for whom conventional therapy is ineffective there are few less morbid options. For this benigndisease, we have successfully used low dose radiotherapy in four patients.Materials/Methods: Four consecutive female patientswith long standing and refractory HS were treated to multiple sites (axillae, the groins, and the inframammary regions) with lowdose electron radiotherapy. Between 600 and 750 cGy was delivered in 3 equal fractions using 6 MeV electrons (Dmax) with a 0.5cm bolus and a 1.0 cm margin surrounding the lesions to treat the apocrine glands in the dermis of the skin and the epidermis tolimit follicular hyperkeratosis. In the lone patient who was treated with 600 cGy, retreatment was necessary in 50% of the sitestreated. One patient supplemented her therapy with a sustained weight loss facilitated by careful dieting. Another patient had beentreated one year prior with 6 MV photon radiotherapy that mimicked our prescribed total dose, but effectively provided only about25% of prescribed dose to the dermis and epidermisResults: With a mean follow up of 28.5 months (range 4-48 months), all patientswere free of recurrence. One patient (4 month follow up patient) had such anxiety about her disease that she decided to undergoradical surgery 4 months from the radiotherapy despite progressive improvement. The time to complete resolution averaged 3-6months from radiotherapy. One patient developed long term pruritus (the patient previously treated with photons). This remains asa controlled but minor intermittent problem. No other patients had side effects of radiotherapy.Conclusion: Conservativemanagement of HA with oral antibiotic therapy and a strict weight loss regimen is an optimal first line approach. However, whenmore radical and invasive surgical options fail or are undesirable, low dose radiotherapy is a viable option.

ParticipantsRichard Lovett JR, MD, Rutland, VT (Presenter) Nothing to Disclose

ABSTRACT

Purpose/Objective(s): In 2013, the American Society of Therapeutic Radiology (ASTRO) released its list of Choosing WiselyInitiatives. One of these initiatives, was to use fractionation schemes which allow less than 10 fractions for the palliation of bonymetastatic disease. Such schemes may use one or five fractions to treat an uncomplicated case of bone metastases. This projectlooks at a rural radiation practice, both before and after a decision was made to employ the Choosing Wisely guidelines wheneverappropriate.Materials/Methods: This is a non randomized, retrospective analysis of 12 months of bone metastasis treatments in asingle provider practice comparing the 6 months before Choosing Wisely to the six months after Choosing Wisely. A total of 37consecutive patients, 63 treatment sites were examined. Fifteen treatment fractions were saved before, 84 treatment fractionswere saved after the guidelines were published.Results: More fractions of radiotherapy were saved when compared to the samelength of time prior to the decision to employ Choosing Wisely Initiatives. This finding, however is seen in a retrospective analysis ofa single physician practice, who decided to adopt the Initiative, thus built in bias existed. Before the Choosing Wisely Initiative wasreleased, 14% of patients received shorter fraction schemes, compared with 68% after. Because of these shorter treamtentschedules, and assuming similar patient charges for treatments, savings after the Initiatives were released were over 5.5 times asmuch as prior to the release for the patient population, as a whole ($69,000 versus $12,000). In a time when health care costs aregrowing faster than the GDP, any savings we can achieve can benefit society as a whole.Numerous assumptions must be made inthe analysis and the numbers are subject to discussion, but no one can deny that a patient with painful bone metastases wouldbenefit from saving almost 4 hours in the car on rural roads. Care givers may be retired, and may not loose wages, but at theaverage wage of $63,000, the average caregiver saved approximately $170.00 in lost wages bringing in their loved one. Theaverage patient who recieved shortened fractionation saved 145 miles of travel and 5 hours and 35 minutes of commuting andtreatment time.Other savings were seen in one patient who needed to be hospitalized for her treatment. Her hospital stay wasreduced by the use of shorter fractionation.No patient in this study required retreatment, the minimum follow up period was 6months. Many patients have passed away from their disease within this follow up period.Conclusion: Shorter fraction schemes whenused as clinically appropriate do offer savings not only to health care payers, but also to patients and patients families.Consideration of Choosing Wisely Initiatives have saved patients time and expense as opposed to a similar time period before theinitiative.


SSJ24-04 A Comparison of Distress Levels in Cancer Patients During Treatment


SSJ24-05 Oncology Acupuncture Program Assessment: A Retrospective Review of Patient Population, CancerDiagnosis and Use of Acupuncture over a 12-month Period at an NCI-Designated Cancer Center


ParticipantsBrian Baumann, Philadelphia, PA (Presenter) Nothing to DiscloseChuan Zeng, Philadelphia, PA (Abstract Co-Author) Nothing to DiscloseIoannis I. Verginadis, Philadelphia, PA (Abstract Co-Author) Nothing to DiscloseCarolyn Vachani, Philadelphia, PA (Abstract Co-Author) Nothing to DiscloseTimothy D. Solberg, PhD, Philadelphia, PA (Abstract Co-Author) Nothing to DiscloseCostas Koumenis, Philadelphia, PA (Abstract Co-Author) Nothing to DiscloseJames M. Metz, MD, Philadelphia, PA (Abstract Co-Author) Nothing to Disclose

ABSTRACT

Purpose/Objective(s): Many patients undergoing radiation therapy (RT) experience acute dermatitis, and topical emollients are usedto ameliorate this condition, including creams with heavy metals. Patients are traditionally advised to avoid lotions for severalhours before RT based on concern that creams might increase skin dose. With modern RT’s improved skin sparing, this traditionalrecommendation may be irrelevant. We hypothesize that the application of either metallic or non-metallic creams before treatmentwould have minimal effect on skin dose.Materials/Methods: We conducted an online, 24-question survey of patients and providersto determine current practices regarding skin creams on the OncoLink website using a convenience sample of users. To evaluatethe dosimetric effect of skin creams, we delivered 200 MU at 100 cm SSD to a 10 x 10 cm field and measured the dose at thesurface and 2 cm depth in a tissue equivalent phantom, with and without application of two common skin creams, Aquaphor andsilver sulfadiazine, using optically stimulated luminescent dosimeters. We assessed the effect of various photon and electronenergies, cream thicknesses, and beam incidence on dose. Results: The survey showed that 22 of 25 patients and providers (85%)either gave or received the advice to avoid applying skin creams prior to RT treatments. This finding was not affected by diagnosis(p=0.6). Measurements showed no difference in dose at the surface or 2 cm depth with or without a relatively thick 1-2 mmapplication of either cream when using enface 6 or 15 MV photons. Similarly, there was no impact on surface dose for 6 MVphotons delivered at incident angles ranging from 15°- 60°. The same application of cream had no effect on surface dose as afunction of beam incident angle, with the exception of a 7% increase at 60° observed only with the silver cream. A significantincrease in surface dose was noted for both 6 and 15 MV photons when a thicker (³3 mm) layer of cream was applied. For 6 MVbeams, the surface dose was 105 cGy with Aquaphor, 102 cGy for the silver cream, and 88 cGy for controls. For 15 MV, the doseswere 70, 60 and 52 cGy, respectively. With 6 and 9 MeV electrons, there was only a 2-5% increase in the surface dose with useof creams. No differences in dose were observed at 2 cm depth. Conclusion: To our knowledge, this is the first dosimetricassessment of the effect of skin creams for radiation dermatitis. Survey results confirmed that patients are routinely advised toavoid creams prior to RT. Our findings suggest that thin or moderately applied skin creams, even if applied just prior to radiation,have minimal impact on skin dose, regardless of beam energy or beam incidence. Applying very thick amounts of skin cream justprior to RT may have a bolus effect with increased surface dose and should be avoided. Studies in mouse models to evaluate theeffect of creams on skin dose using gamma-H2AX IHC staining have been initiated.

ParticipantsKimberly B. Hart, MD, Detroit, MI (Presenter) Nothing to DiscloseJudith Abrams, PhD, Detroit, MI (Abstract Co-Author) Founder, Delphinus Medical Technologies, Inc Officer, Delphinus MedicalTechnologies, Inc Carol Devore, RN, Commerce, MI (Abstract Co-Author) Nothing to Disclose

PURPOSE

Purpose/Objective(s): To assess changes in distress level in cancer patients from diagnosis to end of treatment


Materials/Methods: All newly diagnosed cancer patients at the Charach Cancer Treatment Center, Huron Valley-Sinai Hospital, weregiven a baseline distress assessment using the 10 point NCCN Distress Management Tool (DT). Patients classified as not distressed(ND) if they scored 4 or less. Patients were considered distressed (D) if their score was >4 and referred to social work for furtherassessment. The DT was then administered to ND individuals again at the middle and end of treatment. Demographic data wascollected including age, sex, tumor type, marital status, type of therapy received (chemotherapy alone, chemo/RT or RT alone) aswell as items on the NCCN problem list that accompanies the DT.

RESULTS

Results: 153 patients were surveyed, 48 D patients and 105 ND. More D than ND patients were treated with chemotherapy alone(26% vs 6%) and fewer with RT alone (25% vs 47%) although combination therapy was about the same (50% vs 47%) (p=0.03).Median age of D individuals was 6 years older than the ND (p=0.21). D patients were more likely (31%) than ND (11%) to be single(p=0.01). Breast cancer was the most common tumor type (ND 43%, D 29%) followed by prostate (ND 26% D 8%) and lung cancer(ND 11% D 20%) With respect to the NCCN problem list, emotional (D 81% vs ND 48%) (p=0.0006) and physical problems (D 92%vs ND 44%)

CONCLUSION

Conclusion: In this study, patients who demonstrated no distress at the start of cancer treatment had no increase in distress bythe conclusion of treatment. This may relate to the difficulty of capturing changes in distress in a patient survey. Given thatemotional and physical problems were significant complaints in patients with distress at the start of treatment, more attentionneeds to directed at these issues by clinicians. [1]

Participants

SSJ24-06 The Impact of Body Mass Index on Time from Diagnosis to Surgery and Time from Surgery toRadiation in Patients with Breast Cancer


Angie L. Rademacher, Portland, OR (Presenter) Nothing to DiscloseShushan Rana, MD, Portland, OR (Abstract Co-Author) Nothing to DiscloseCharles R. Thomas JR, MD, Portland, OR (Abstract Co-Author) Nothing to DiscloseYiyi Chen, Portland, OR (Abstract Co-Author) Nothing to DiscloseOleg Sostin, BS, Beaverton, OR (Abstract Co-Author) Nothing to Disclose

PURPOSE

The management of cancer treatment related side-effects is a continuous challenge to patients and healthcare providers alike. Inthe therapeutic armamentarium, alternative medicine is slowly gaining popularity as a complementary or substitutive managementoption. Among well-known alternative medicine modalities, acupuncture has been shown in several studies to reduce or eliminateradiation therapy (RT) induced effects such as RT-induced xerostomia in head and neck cancer and RT-related fatigue. In thisstudy, we analyzed the demographics among RT patients who chose acupuncture, which symptoms prompted referral, andprevalence of combined modalities among these patients.


Records of 50 cancer patients who utilized acupuncture between May 2013 and April 2014 were reviewed at our institution. Thesubset chosen for final analysis was limited to patients who underwent radiation therapy either alone or in combination with otherstandard cancer treatment modalities. Variables measured included gender, age, payment method, cancer type, treatmentmodalities, chemotherapy class, and type and number of symptoms prompting acupuncture referral.

RESULTS

Among 50 pts analyzed in our initial set of acupuncture patients, 26 pts, 8 men (mean age = 64.5 yrs) and 18 women (mean age =58.5 yrs) received radiation therapy. Twenty-two pts also received chemotherapy, and 15 pts among the chemoradiation cohortunderwent surgery. Breast cancer pts (n=11) were the most prevalent users of acupuncture followed by head and neck (n=4) andlung cancer (n=3). Most patients (n=20) requested assistance with 1-2 symptoms with the most common symptoms beingneuropathy (n=6), arthralgias (n=6), and nausea (n=6). Among the breast cancer cohort, the most common chief complaint werearthralgias (n=6), myalgias (n=5), and neuropathy (n=4) and the most commonly used chemotherapy were taxanes (n=9).

CONCLUSION

Among RT patients, women were more prevalent users of acupuncture with majority diagnosed with breast cancer. The majority ofpatients also received either concurrent or sequential chemotherapy. Neuromusculoskeletal complaints were the most commonreason for acupuncture referral.


These data will be used in future analyses to further characterize symptoms in order to strengthen outcomes evaluations and tailoremphasis to cancer subpopulations' specific symptoms.

ParticipantsApar Gupta, Boston, MA (Presenter) Nothing to DiscloseShivani Khanna, Boston, MA (Abstract Co-Author) Nothing to DiscloseAnkit Agarwal, BS, Boston, MA (Abstract Co-Author) Nothing to DiscloseMuhammad M. Qureshi, MBBS,MPH, Boston, MA (Abstract Co-Author) Nothing to DiscloseDivya Ahuja, Boston, MA (Abstract Co-Author) Nothing to DiscloseAriel E. Hirsch, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose

ABSTRACT

Purpose/Objective(s): In breast cancer, both biological and social factors may delay the time from diagnosis to surgery and thetime to initiation of radiation therapy (RT). In this study, we analyze the impact of body mass index (BMI) on time from initialdiagnosis of breast cancer to surgery (TTS) and from surgery to RT (TTR) in a large cohort of breast cancerpatients.Materials/Methods: A total of 1409 patients were diagnosed with breast cancer at our institution between 2004 and 2014.Of these, 1073 patients underwent surgery as first treatment and had BMI information available in the electronic health record. Weclassified patients as normal weight, overweight and obese by BMI (18.5-Results: BMI had no statistically significant impact onTTS. TTS for normal weight (N=252), overweight (N=345) and obese patients (N=476) was 35.2 days, 36.7 days and 33.7 days,respectively (p=0.555). In a subset analysis of 489 patients undergoing follow-up EBRT, BMI did have an impact on TTR. Patientswith normal weight (N=104) had the lowest TTR at 64.6 days. Obese patients (N=241) reported longer TTR at 71.7 days howeverthe finding failed to reach statistical significance (p=0.33). Patients who were classified as overweight (N=144) had a significantlyhigher TTR at 85.3 days (p=0.01).Conclusion: In this large retrospective analysis, BMI was associated with a delayed time fromsurgery to radiation in patients classified as overweight with a BMI between 25-<30. Interestingly, obese patients with a BMI over30 did not have a statistically longer TTR; further analysis of the overweight patient subset may reveal the reason for theiruniquely longer TTR. In breast cancer, several studies link a BMI over 25 to a higher breast cancer related mortality rate. Furtherresearch must be done to further explore the impact of BMI on the quality and timeliness of care as well as its potential impact onpatient outcomes.

RC407

Quality and Safety in GU Radiology: Update on Best Practices, Contrast Material, and Radiation Dose


GU SQ


ParticipantsGiles W. Boland, MD, Boston, MA (Coordinator) Principal, Radiology Consulting Group; Royalties, Reed ElsevierRichard H. Cohan, MD, Ann Arbor, MI, ([email protected]) (Presenter) Consultant, General Electric Company; ; ; James A. Brink, MD, Boston, MA (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Understand the background and current status of best practice clinical and workflow management and its imperitive for improvingpatient outcomes. 2) To review indications for premedication prior to contrast material administration. To summarize the currentunderstanding of iodinated contrast media nephrotoxicity. To describe common errors made in treating contrast reactions. 3) Tounderstand the requirement to match radiation dose according to the individual patient, clinical question and modality used. Tooutline meaningful radiation metrics including organ dosages and the overall radiation absorbed to estimate patient risk.

ABSTRACT

BEST PRACTICES: Increasingly medicine is being defined and evaluated based on patient outcomes rather than procedural events.While best practices are evolving and sometimes incomplete, many do exist, yet there is marked departmental variation from oneorganization to another. This session will outline why and how best practice implementation, particularly as it relates to IV contrastuse and radiation dose, is essential to achieve better patient outcomes. This will require evaluation of current practices andcomparison to nationally driven guidelines, with subsequent compliance to guidelines where they exist. CONTRAST SAFETY: Somepatients have contrast reactions despite premedication. Patients who have repeated reactions in this setting tend to havereactions of similar severity. Studies performed with control groups suggest that there is minimal to no increased risk of contrast-induced renal failure in patients who receive iodinated contrast material; however, the control groups likely included patients atincreased risk of acute kidney injury. Some errors treating contrast reactions relate to failure to administer epinephrine or using thewrong dose / wrong route. The act of administering this drug can also be problematic. RADIATION DOSE: In all radiologicalexaminations that utilize x-rays, there are always three important issues that must be taken into consideration. The first relates tothe appropriate amount of radiation to be used, which must always explicitly take into account the imaging task at hand as well asthe physical characteristics of the patient undergoing the CT examination. The second issue is how to transform the radiationincident on the patient into the organ doses received which are essential to understanding (any) patient risks. The finalconsideration is to understand the radiological significance of the radiation absorbed by the patient, and to estimate (any)radiological risks, as well as the corresponding uncertainties.

RC415A Image Quality and Interpretation

RC415B MR BI-RADS 3

RC415C Challenging Cases

RC415

Breast MR Imaging (An Interactive Session)

Tuesday, Dec. 1 4:30PM - 6:00PM Location: E450A

BR MR SQ


Participants

Sub-Events

ParticipantsDebra M. Ikeda, MD, Stanford, CA (Presenter) Consultant, F. Hoffmann-La Roche Ltd; Consultant, Bracco Group

LEARNING OBJECTIVES

1) To review standard MRI acquisition parameters recommended by ACR Breast MRI BI-RADS. 2) To review MRI Interpretationaccording to ACR Breast MRI BIRADS terminology.

ParticipantsDebra L. Monticciolo, MD, Temple, TX (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) To review the current literature for BIRADS 3 in the MR setting. 2) To understand interpretations for which BIRADS 3 would orwould not be appropriate.

ABSTRACT

Discussion will include the current literature on use of BIRADS 3, with attention to the MR setting. Cases where BIRADS 3 would beconsidered as well as cases not appropriate for BIRADS3 at MR will be shown.

ParticipantsSujata V. Ghate, MD, Durham, NC (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Identify challenging cases on breast MRI. 2) Recognize MR imaging findings of unusual breast lesions. 3) Review do's and don't ofthe breast MRI report. 4) Recommend appropriate management for difficult or esoteric lesions seen on MRI.

ABSTRACT

This lecture will review challenging cases on breast MRI. Participants will learn to identify MR imaging features of common breastdiseases, recognize unusual and esoteric lesions, understand the importance of a clear and concise MRI report, and manage difficultcases seen on breast MRI. A total of 12 cases will be reviewed and imaging findings and appropriate management for each case willbe discussed. At the conclusion of the case conference, audience participants will have the opportunity to ask questions anddiscuss unusual cases.

RC432A Business Intelligence and Analytics in Radiology: Scorecards, Dashboards, Big Data, and Beyond

RC432B Quality: Going Beyond the Metrics

RC432C Demonstrating Quality to CMS and the Other Payors

RC432

Measuring Quality in Radiology

Tuesday, Dec. 1 4:30PM - 6:00PM Location: N230

LM SQ


Participants

Sub-Events

ParticipantsPaul J. Chang, MD, Chicago, IL, ([email protected]) (Presenter) Co-founder, Stentor/Koninklijke Philips NV;Researcher, Koninklijke Philips NV; Medical Advisory Board, lifeIMAGE Inc; Medical Advisory Board, Merge Healthcare Incorporated

LEARNING OBJECTIVES

1) The technical steps required to develop and implement dashboards and scorecards (including data/state aggregation, semanticnormalization, modeling, data mining, and presentation) will be discussed. 2) Specific strategies and technologies that can be usedto create dashboards and scorecards (including HL7, DICOM, ETL, web services, and SOA) will be illustrated. 3) Strategies tocreate a sustainable and agile architecture to support advanced business intelligence and analytics (BIA) tools will be explored.(This course is part of the Leadership Track)

ABSTRACT

Current and near future requirements and constraints will require radiology practices to continuously improve and demonstrate thevalue they add to the enterprise. Merely "managing the practice" will not be sufficient; groups will be required to compete in anenvironment where the goal will be measurable improvements in efficiency, productivity, quality, and safety. Although the phrase"one cannot improve a process unless one can measure it" is a familiar platitude, it is an increasingly important and relevantconcept. The proper leveraging of formal Business Intelligence and Analytics (BIA) is a critical, absolutely essential strategy for anyradiology group. Although currently underutilized, concepts such as Key Performance Indicators (KPIs), tactical dashboards, andstrategic scorecards, should be familiar tools for radiology groups attempting to "navigate disruption."

ParticipantsJonathan W. Berlin, MD, Evanston, IL (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Define population health and articulate the essential role of quality in this new health care paradigm. 2) Consider the key role ofpatient experience in the concept of radiology quality. 3) Explore the concepts of quality and value in radiology. (This course is partof the Leadership Track)

ABSTRACT

Quality has become an essential component of radiology practices. But what is quality and how is it measured? The course willattempt to answer these questions from three perspectives. First, the perspective of quantitative radiology quality metrics andways of measuring them will be explored, and methods of data analytics will be considered. Second, the concept of quality as itapplies to a new heath care delivery paradigm of population health will be analyzed. Population health is a framework in whichhealth care entities and providers are tasked with keeping an entire defined population healthy, rather than the current healthcaredelivery system that focuses largely on individual sick patients. The third speaker will address the essential role of patientsatisfaction and positive patient experience in the concept of quality in radiology. These areas are increasingly prevalent in on linerating sites, a domain that is not typically assessed with current standardized quality metrics.

ParticipantsWilliam T. Thorwarth JR, MD, Reston, VA (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Define population health and articulate the essential role of quality in this new health care paradigm. 2) Consider the key role ofpatient experience in the concept of radiology quality. 3) Explore the concepts of quality and value in radiology. (This course is partof the Leadership Track)

ABSTRACT

Quality has become an essential component of radiology practices. But what is quality and how is it measured? The course willattempt to answer these questions from three perspectives. First, the perspective of quantitative radiology quality metrics andways of measuring them will be explored, and methods of data analytics will be considered. Second, the concept of quality as itapplies to a new heath care delivery paradigm of population health will be analyzed. Population health is a framework in whichhealth care entities and providers are tasked with keeping an entire defined population healthy, rather than the current healthcaredelivery system that focuses largely on individual sick patients. The third speaker will address the essential role of patientsatisfaction and positive patient experience in the concept of quality in radiology. These areas are increasingly prevalent in on linerating sites, a domain that is not typically assessed with current standardized quality metrics.

RC523A Medical Device Security in a Connected World

RC523B Knowing if Your Imaging Systems are Secure and Keeping Them That Way

RC523C The US Government and Medical Device Security

RC523

Digital Information Security and Medical Imaging Equipment: Threats, Vulnerabilities and Best Practices

Wednesday, Dec. 2 8:30AM - 10:00AM Location: S403B

IN PH SQ


Participants

Sub-Events

ParticipantsKevin McDonald, Rochester, MN, ([email protected]) (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Understand the changing environment of network and internet connected devices and software. 2) Be aware of the motivationsand tatics of current threat actors. 3) Understand common security issues found in medical devices. 4) Know simple actions thatcan decrease risk.

ABSTRACT

Medical devices are increasingly becoming dependent on technology and network connectivity, at a time that the electronicenvironment is becoming more dangerous. Because of this medical devices and systems can become easy targets for attackersattempting to access PHI, disrupt patient care or even harm a patient. When tested, these devices have been shown to havemultiple vulnerabilities. These vulnerabilities range from hardcoded passwords, publically available service passwords and noencryption of patient data. Because of this institutions using these devices need to work with their vendors to improve the securityof medical devices and take actions themselves to help protect their environment and patients.

ParticipantsJ. Anthony Seibert, PhD, Sacramento, CA, ([email protected]) (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Understand the vulnerabilities of imaging system modalities to security and privacy breeches. 2) Determine ways to protect andsecure imaging systems from internal and external threats. 3) Describe institutional best-practices to maintain protection yetprovide necessary accessibility for imaging modalities.

ParticipantsKevin Hemsley, Idaho Falls, ID (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) What are industrial control systems (ICS) and how do they play in the field. 2) What is the role and capabilities of ICS-CERT(Industrial Control Systems Cyber Emergency Response Team). 3) What is some steps that can be taken to protect ICSs.

RC527

Changing the Way Radiologists Work: How and Why We Need to Embrace a Culture of Safety

Wednesday, Dec. 2 8:30AM - 10:00AM Location: E351

HP SQ


ParticipantsKimberly E. Applegate, MD, MS, Zionsville, IN, ([email protected]) (Coordinator) Nothing to DiscloseKimberly E. Applegate, MD, MS, Zionsville, IN, ([email protected]) (Moderator) Nothing to DiscloseGiles W. Boland, MD, Boston, MA (Presenter) Principal, Radiology Consulting Group; Royalties, Reed ElsevierNabile M. Safdar, MD, Alpharetta, GA (Presenter) Shareholder, Montage Healthcare Solutions, Inc;

LEARNING OBJECTIVES

1) To describe how technology can accelerate an existing culture of safety in radiology. 2) To assess the risks of poor technologyimplementations when there is a weak safety culture. 3) To identify the highest impact opportunities for improving safety in one'spractice through technology. 4) To assess the maturity of one's informatics infrastructure to support a safety program.

RC553A Improving Access and Appropriateness

RC553B Improving Value of Radiology Reports

RC553C Improving Communication of Critical Results and Follow-up Recommendations

RC553

Next Generation IT to Improve Quality and Safety

Wednesday, Dec. 2 8:30AM - 10:00AM Location: S405AB

IN PR SQ

AMA PRA Category 1 Credits ™: 1.50ARRT Category A+ Credit: .50

ParticipantsRamin Khorasani, MD, Roxbury Crossing, MA (Moderator) Consultant, Medicalis Corp

ABSTRACT

Improving healthcare system performance is a major national focus. An important element of performance improvement inhealthcare is national adoption and meaningful use of interoperable health information technology tools, supported by federalregulations as part of Health Information technology and Economic Health Act (HITECH). Radiology has been a leader in adoption ofhealth IT tools and solutions. In this session, we will review some key, next generation health IT requirements to improve quality ofcare and patient safety while reducing waste.The speakers will use case example to demonstrate how health IT tools can be usedto improve access to imaging, improve appropriateness of imaging ordering, improving radiology report value, enhancecommunication of critical test results, and enable appropriate follow up imaging and care coordination for patients.

Sub-Events

ParticipantsKeith D. Hentel, MD, MS, New York, NY, ([email protected]) (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Understand avialable technologies available for improving access to imaging practices. 2) Understand available technologies forimproving appropraiteness of imaging performed.

ParticipantsRoss W. Filice, MD, Washington, DC, ([email protected]) (Presenter) Nothing to Disclose

ParticipantsRamin Khorasani, MD, Roxbury Crossing, MA (Presenter) Consultant, Medicalis Corp

RC554A Introduction

RC554B Platforms and Security

RC554C Apps, Bandwidth, and Integration

RC554

Mobile Computing Devices

Wednesday, Dec. 2 8:30AM - 10:00AM Location: S404CD

IN SQ


ParticipantsDavid S. Hirschorn, MD, Staten Island, NY, ([email protected]) (Moderator) Nothing to DiscloseAsim F. Choudhri, MD, Memphis, TN (Moderator) Nothing to DiscloseGeorge L. Shih, MD, MS, New York, NY (Moderator) Consultant, Image Safely, Inc; Stockholder, Image Safely, Inc; Consultant,Angular Health, Inc; Stockholder, Angular Health, Inc;

Sub-Events

ParticipantsDavid S. Hirschorn, MD, Staten Island, NY (Presenter) Nothing to Disclose

ParticipantsGeorge L. Shih, MD, MS, New York, NY (Presenter) Consultant, Image Safely, Inc; Stockholder, Image Safely, Inc; Consultant,Angular Health, Inc; Stockholder, Angular Health, Inc;

LEARNING OBJECTIVES

1) Mobile Health: Discuss mobile healthcare trends and evolution involving Apple iOS and Google Android, with specific focus onmobile health apps and platforms, including Apple HealthKit and Apple ResearchKit. 2) Mobile Security: Provide basic understandingof different security concerns in mobile health and discuss options in the healthcare setting.

ABSTRACT

Mobile healthcare devices of all shapes and sizes are now ubiquitous in clinical setting. Radiologists and other providers areleveraging mobile solutions in their clinical workflow. The major mobile platforms provide distinct advantages for both app developersand end users (ie, clinicians and patients) in the healthcare setting. Both iOS and Android platforms have development toolkits thatallow for health-related apps. Apple has released HealthKit and ResearchKit, which are more medically focused, and several appsare already available which leverage these new capabilities. A major EHR vendor, EPIC, now has the ability to directly communicateand with a patient's iPhone with bi-directional data-sharing. Wearable devices, such as the Apple iWatch, and other third partymobile health devices are also discussed. The wearable and portable devices will continue to accelerate the shift to mobilehealthcare.Mobile devices will need to have the same or enhanced security compared with traditional computers because ofincreased portability and the Bring Your Own Device (BYOD) phenomenon where clinicians are increasingly using their personaldevices for work. Managing enterprise mobile security on a wide range of work and personal mobile devices will remain challengingalthough can be alleviated by using Mobile Device Manager software which can deploy updates and enforce security policies.Shared mobile devices for patients in the clinical setting may also present similar challenges.

ABSTRACT

Mobile healthcare devices of all shapes and sizes are now ubiquitous in clinical setting. Radiologists and other providers areleveraging mobile solutions in their clinical workflow. The major mobile platforms provide distinct advantages for both app developersand end users (ie, clinicians and patients) in the healthcare setting. The two main platforms for tablet mobile devices are Apple iOSand the Google Android. Mobile devices will need to have the same or enhanced security compared with traditional computersbecause of increased portability and the Bring Your Own Device (BYOD) phenomenon where clinicians are increasingly using theirpersonal devices for work. Managing enterprise mobile security on a wide range of work and personal mobile devices will remainchallenging although can be alleviated by using Mobile Device Manager software which can deploy updates and enforce securitypolicies. Shared mobile devices for patients in the clinical setting may also present similar challenges.

ParticipantsAsim F. Choudhri, MD, Memphis, TN (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) To have an understanding of available applications available for mobile medical imaging, including native clients, web clients, andvirtual desktop/terminal server approaches. 2) To have an understanding of bandwidth concerns in mobile medical imaging, includingdevice data handling, network speeds, and possible bandwidth cost issues. 3) To have an understanding of possible clinicalimplementations of mobile medical imaging within radiology departments and in health care networks overall.

ABSTRACT

Applications: There are several vastly different approaches to mobile viewing of medical images. Native clients are programs writtenusing a software development kit for a given platform. These clients can retrieve data from remote servers and view locally storedimage data. Web clients are web-based programs which are often (but not always) platform independent. They will typically accessremotely stored data which may be stored in a local cache but is usually not permanently stored on the mobile device. Virtualdesktop/terminal server software allows a mobile device to access a remote computer or server. The remote server handles all

RC554D Displays and Quality Assurance

higher level processing and data storage, minimizing the processing requirements of the mobile device but possibly strainingbandwidth limitations. Examples of several applications using each of these approaches will be presented, with a discussion of prosand cons for each method as it pertains to an individual user and as it pertains to widespread implementation within a healthcarenetwork. Bandwidth: Viewing medical images may require transfer of datasets that are tens or hundreds of megabytes in size. Thisprovides a special challenge for mobile devices which typically receive data via wireless communication. If using a cellular network,network bandwidth can be a limiting factor (as can data transfer costs). File compression can reduce the size of files, howeverrequires data processing power and may involve compromises in image quality. Once data is on a device, image processing mayoverwhelm its processing capabilities compared with dedicated PACS workstations. We will discuss both network and devicebandwidth concerns as it relates to mobile medical imaging, and possible solutions for overcoming obstacles. Integration into ahealthcare system: Mobile review of medical imaging is a tool which has potential to significantly change health care delivery, butthe specifics for implementation are unclear. After a device platform has been selected, security protocols established, andbandwidth concerns solved, each institution will need to determine what role this technology will play. Possibilities include radiologyresidents (or even faculty) consulting with subspecialty faculty, surgeons and interventionalists triaging patients for procedures andfor procedure planning, however these approaches are simply extensions of existing practices. New frontiers in consultation will bediscussed, including an example involving mobile imaging review in a multidisciplinary stroke team. Guidance will also be providedregarding training and establishing institutional "standard operating procedures" documents. The current state of medical-legalconcerns and risk management strategies will also be discussed.

ParticipantsDavid S. Hirschorn, MD, Staten Island, NY (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Discuss ranges of spatial and contrast resolution for medical imaging. 2) Explore options for calibration and quality assurance. 3)Understand the impact of ambient light and viewing distance and angle on medical image display.

ABSTRACT

Mobile devices have significantly smaller displays than desktop or even laptop computers to make them lighter and more easilytransported. They are also designed for shorter viewing distances which require smaller pixels. The smaller total display size tendsto reduce the number of pixels, while the smaller pixel size tends to increase the number of pixels. On balance, these displaystypically have considerably fewer pixels than their stationary counterparts. Nonetheless, even desktop displays typically have lessresolution than the original image size of a radiograph which is typically about 5 megapixel (MP) for a chest radiograph. And bothtypes of displays have more resolution than a single CT image, which is 0.25 MP. Since these devices do allow zooming andpanning, they may be suitable for image interpretation under controlled circumstances. The main purpose of the DICOM Part 14Grayscale Display Function is to ensure that contrast is preserved across the range of shades of gray from black to white,particularly at the edges where uncalibrated displays tend to fall off. With desktop displays this can be measured with aphotometer, either external or built-in, and graphics adapter adjustments can be made to make the display conformant. Mobiledevices typically do not offer this degree of adjustability. This requires a different approach to DICOM curve conformance, and areasonable alternative is to present the user with a visual challenge to identify low contrast targets placed randomly on the display.If the user can find them and tap on them, then the display may be considered compliant, and if not, then the display should notbe relied upon.

SSK16-01 A Computer Program to Assess Organ Doses for Pediatric and Adult Patients Undergoing CT Scans


SSK16-02 Can Gaming Consoles Be Used to Improve X-Ray Imaging? A Feasibility Study


SSK16

Physics (Radiation Dose Measurement)

Wednesday, Dec. 2 10:30AM - 12:00PM Location: S404AB

CT PH SQ



ParticipantsMitchell M. Goodsitt, PhD, Ann Arbor, MI (Moderator) Research collaboration, General Electric Company

Sub-Events

ParticipantsChoonsik Lee, PhD, Rockville, MD (Presenter) Nothing to DiscloseKwang Pyo Kim, Suwon, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseWesley E. Bolch, PhD, Gainesville, FL (Abstract Co-Author) Nothing to DiscloseLes R. Folio, DO, MPH, Bethesda, MD (Abstract Co-Author) Research agreement, Carestream Health, Inc

PURPOSE

To develop a computer program to assess organ doses for pediatric and adult patients undergoing computed tomography (CT)scans using a series of reference pediatric and adult computational human phantoms coupled with the Monte Carlo transportsimulation of x-ray in CT scans.


A comprehensive set of organ dose conversion coefficients, organ dose normalized to CTDIvol, were calculated using 10 pediatricphantoms, recently adopted by International Commission on Radiological Protection (ICRP) as international reference, and the ICRPreference adult phantoms (ICRP Publication 110). The simulated organ doses were experimentally validated by physicalanthropomorphic phantoms. A graphical user interface was designed to obtain the user input of patient and scan parameters. Theroutines for Size Specific Dose Estimates (SSDE) and organ doses under tube current modulation scans (based on mAs dataabstracted from DICOM headers) were also programmed. To evaluate the performance of the computer program, organ doses werecalculated for 10 pediatric and adult sample patients, and compared with existing CT dosimetry tools.

RESULTS

A computer program with GUI was developed for users to input CT scan parameters and assess organ doses and other dosedescriptors as output. The calculated organ doses matched the measured values within 15%. The organ doses calculated for the10 sample patients using our program showed up to 200% discrepancies compared to the existing CT dose calculators (CTDosimetryand CT-Expo). Detailed analysis of the anatomy of phantoms revealed that realistic human phantoms are crucial to improvingaccuracy in CT organ dosimetry.

CONCLUSION

A user-friendly computer program for CT dose calculations was developed and validated. The program is based on the realistic ICRPreference phantoms and up-to-date red bone marrow dosimetry methods, and provides several convenient features compared tothe existing tools.


The computer program developed in this study is a convenient tool providing organ doses for CT patients based on the ICRPreference phantoms. The program will be useful for epidemiological studies of CT risk and patient dose monitoring.

ParticipantsSteven Don, MD, Saint Louis, MO (Presenter) Research Grant, Carestream Health, Inc; ; Robert MacDougall, MSc, Cambridge, MA (Abstract Co-Author) Nothing to DiscloseWilliam Clayton, St. Louis, MO (Abstract Co-Author) Nothing to Disclose

PURPOSE

To test the feasibility of using gaming console technology to improve the quality of X-ray projection imaging by automaticallymeasuring body part thickness and mitigating the causes of repeat examinations.


Proprietary software was developed for the Microsoft Kinect 1.0 for Windows using C#. Both the optical camera and infrared sensoroutputs were recorded and tested with a mock-up wall stand. The software was designed to control radiation dose variation bymeasuring body-part thickness. It also was designed to reduce common reasons for repeating images including wrong body part,motion, positioning, and clipped anatomy.

RESULTS

The system recognized body part and left/right side of the body to reduce taking the wrong body part. Thickness measurements

SSK16-03 Making Proper Use of the ICRU/AAPM CT Dose Phantom: Recommendations and Limitations


SSK16-04 Improving Staff Radiation Protection during Computed Tomography Using a Simple Traffic LightSystem


The system recognized body part and left/right side of the body to reduce taking the wrong body part. Thickness measurementswere automatically displayed with a precision of 1 mm at the central ray, defined body part, or at a user-specified point. Thesystem identified the relationship of the patient's ordered anatomy with respect to the location of automatic exposure chambers(AECs) and image receptor. The software was designed to highlight the body part in red when it was not overlying the AECs, yellowwhen partially on a specified AEC, and green when completely covering that AEC. Motion was tracked graphically over timedisplayed with red indicating gross motion, yellow as slight motion, and green as no motion. Clipped anatomy was displayed with anoverlay of the collimated light field. Positioning was confirmed with the optical camera. The display output included a stylized bodywith highlighted body part, optical visualization of the patient, thickness measurement, and motion over time displayed graphicallyas shown in the figure (shown: left hand centered over the center AEC, recent but no current motion, and 19 mm thick in the APprojection at the central ray).

CONCLUSION

This feasibility study shows that body-part thickness can be measured automatically and can aid in setting technique based onpatient thickness without physical contact measurement (e.g. calipers). The system can reduce repeat rates by confirmation of thecorrect body part, and checking for motion, positioning, and collimation immediately before the radiograph.


This feasibility study indicates that technology can be adapted from mass-produced gaming consoles to control radiation dose andreduce repeat rates. This device can help the radiology community adhere to the ALARA principle.

ParticipantsDonovan M. Bakalyar, PhD, Detroit, MI (Presenter) Nothing to DiscloseErin Angel, PhD, Tustin, CA (Abstract Co-Author) Employee, Toshiba CorporationJohn M. Boone, PhD, Sacramento, CA (Abstract Co-Author) Research Grant, Siemens AG Research Grant, Hologic, Inc Consultant,Varian Medical Systems, Inc Robert G. Dixon, MD, Chapel Hill, NC (Abstract Co-Author) Nothing to DiscloseSarah E. McKenney, PhD, Washington, DC (Abstract Co-Author) Consultant, RadCal CorporationMichael F. McNitt-Gray, PhD, Los Angeles, CA (Abstract Co-Author) Institutional research agreement, Siemens AG; Researchsupport, Siemens AG; ; ; ; ; Wenzheng Feng, New York, NY (Abstract Co-Author) Nothing to DisclosePaul B. Sunde, Monrovia, CA (Abstract Co-Author) Shareholder, Radcal Corporation; Employee, Radcal CorporationKeith J. Strauss, FAAPM, FACR, Cincinnati, OH (Abstract Co-Author) Research Consultant, Koninklijke Philips NV; Speakers Bureau,Koninklijke Philips NVHeather Chen-Mayer, PhD, Gaithersburg, MD (Abstract Co-Author) Nothing to DiscloseSue Edyvean, London, United Kingdom (Abstract Co-Author) Nothing to DiscloseRichard L. Morin, PhD, Jacksonville, FL (Abstract Co-Author) Nothing to DiscloseShuai Leng, PhD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseJeffrey H. Siewerdsen, PhD, Baltimore, MD (Abstract Co-Author) Research Grant, Siemens AG; Consultant, Siemens AG; ResearchGrant, Carestream Health,Inc; License agreement, Carestream Health,Inc; License agreement, Elekta AB; ; ;

Background

The ICRU/AAPM CT phantom was designed by AAPM Task Group 200 to implement the recommendations of TG111 for testing theradiation output of CT machines over all irradiation lengths L ; it is not limited to the single point at 100 mm determined usingcurrent CTDI methodology. It can also be employed over several types of CT platforms; however, there are situations where theresults have to be carefully interpreted in order to avoid improper cross-platform comparisons.

Evaluation

For determining the rise to equilibrium function h ( L ) up to its limiting value, a small radiation detector is placed at the radialdistance of interest in the central plane of the phantom. Two methods can be used: 1) integrated exposure is recorded for scans ofvarying length L for multi-detector CT (MDCT) or for collimations of varying width L for fixed-table platforms, symmetric about thelongitudinal center of the phantom; 2) a single scan through the entire phantom while recording the exposure rate, dX / dt . MonteCarlo calculations have shown good agreement with measurement. Modifications to both methods have been used formeasurements on interventional C-arms with CT reconstruction capability, including machines limited to sub 360° rotations.

Discussion

Helical scans using a narrow collimation and low pitch provide the high sampling frequency essential for the implementation ofmethod 2 on multi-detector CT (MDCT) machines. Method 1 with L as the collimation width is often a better choice for C-arm CT.Also, with C-arm CT, the beam angle will often not intercept the entire diameter of the 30 cm phantom. Dose measurements arestill meaningful since irradiation still occurs beyond the beam angle but the radial dose distribution will differ substantially near theedge of the phantom. A long phantom with smaller diameter would foster a more direct comparison between C-arm and MDCT.

Conclusion

The ICRU/AAPM phantom is a robust and flexible tool in determining h ( L ) with alternate measurement methods which showconsistent results. For alternate platforms, there may be constraints not normally experienced in MDCT than need to be considered.

ParticipantsChristina Heilmaier, MD, Zurich, Switzerland (Presenter) Nothing to DiscloseNiklaus Zuber, Zurich, Switzerland (Abstract Co-Author) Nothing to DiscloseAndre Liebing, Zurich, Switzerland (Abstract Co-Author) Nothing to DiscloseDominik Weishaupt, MD, Zurich, Switzerland (Abstract Co-Author) Nothing to Disclose

SSK16-05 Dose-splitting to Obtain Repeat Datasets of Varying Radiation Dose Levels without RepeatAcquisition: Methodology and Verification


PURPOSE

When scanning emergency and intensive-care patients medical staff frequently needs to remain in the scanner room to supervisepatients during computed tomography (CT) scans. Often there is high uncertainty concerning staff's best position from a radiationprotection perspective. The purpose was to establish a simple system, which helps medical staff to find the optimal position withregard to their own radiation protection.


To provide guidance for staff we performed dose measurements (µGy/s) on different positions near the CT table using a portabledose detector. Based on these dose values we placed stickers with a diameter of 30 cm on different positions of the floor accordingto the traffic light system (red = worst position; orange = intermediate position; green = best position). Thereafter, we asked staffto provide evaluation of the new system using a 5-point-scale (1 = not true, 3 = undetermined, 5 = true).

RESULTS

Dose measurements yielded lowest radiation exposure of staff on the lateral part of the CT chassis (mean dose rate, 0.2 µGy/s)and highest values near the CT table close to the gantry (mean dose rate, 20.2 µGy/s). Intermediate dose rates were measured atthe opposite end of the gantry and approximately 1.5 meters away from the table (mean rate, 1.9 µGy/s). Survey of 36 staffmembers revealed that overall judgment of the traffic light system was very positive (mean rating, 4.8). The majority ofrespondents tried to follow the stickers during the CT scan (mean rating, 4.6) and felt safer since the sticker were placed on thefloor (mean rating, 4.5). However, some mentioned that it sometimes was impossible to stand in the green sticker as patientmonitoring was limited. Evaluation of knowledge concerning best own position showed that many staff members had considerablymisjudged their previous radiation exposure (mean rating of 'I already knew before where best position was', 3.4), which wasespecially evident in those with only few work experience (1-2 years; mean rating, 1.8).

CONCLUSION

From a radiation protection perspective best position of staff members is on the lateral part of CT chassis, while it is worst to standnear the table close to the gantry. By implementing a traffic light system staff protection and reassurance can be improved.


A traffic light system helps staff members to find the best position during a CT scan to receive lowest possible radiation dose.

ParticipantsDaniele Marin, MD, Cary, NC (Presenter) Nothing to DiscloseJuan Carlos Ramirez-Giraldo, PhD, Malvern, PA (Abstract Co-Author) Employee, Siemens AGYakun Zhang, MS, Durham, NC (Abstract Co-Author) Nothing to DiscloseKatharine Grant, PhD, Rochester, MN (Abstract Co-Author) Employee, Siemens AGRendon C. Nelson, MD, Durham, NC (Abstract Co-Author) Consultant, General Electric Company Consultant, Nemoto Kyorindo Co,Ltd Consultant, VoxelMetrix, LLC Research support, Bracco Group Research support, Becton, Dickinson and Company SpeakersBureau, Siemens AG Royalties, Wolters Kluwer nvEhsan Samei, PhD, Durham, NC (Abstract Co-Author) Nothing to DiscloseAchille Mileto, MD, Durham, NC (Abstract Co-Author) Nothing to DiscloseAlex Bibbey, MD, Durham, NC (Abstract Co-Author) Nothing to Disclose

PURPOSE

To develop and validate a methodology for precise and accurate comparison of three distinct radiation dose levels from a singleMDCT acquisition


The ACR CT accreditation phantom (Gammex 464) was scanned using a third-generation dual-source MDCT platform (SomatomDefinition FORCE). The scanner was equipped with a prototype research scan mode that allows user-defined partitioning of theradiation dose between the two x-ray tubes (A and B) by independently selecting the milliamperage value of each tube whenoperating in the dual-source (DS) mode. All scans were performed using both single-source (SS) and DS acquisitions, at constant120 kVp. For each DS acquisition, three radiation dose levels were reconstructed using the projection data of each radiation tubealone (A or B) or the two tubes combined (A + B). Six different dose levels were obtained for each acquisition mode, including (a)200, 150, 100, 75, 50, and 25 mAs for SS and (b) 200 mAs (A = 150; B = 50 mAs) and 100 mAs (A = 75; B = 25 mAs) for DSacquisitions. Objective assessment of image quality was performed and compared between the SS and DS acquisitions. Analysisincluded evaluation of first order image quality metrics (noise, contrast, and CNR) as well as a more comprehensive detectabilityindex, which accounts for the impact of noise, noise power spectrum (NPS), contrast, contrast-dependent task transfer function(TTF), task definition, and eye filter. Radiation dose data were also collected (CTDIvol, DLP).

RESULTS

For equal radiation dose levels, there was no significant difference between SS and DS acquisitions for measured image qualitymetrics, including noise (average difference, 1.4%; range, 0.2-3.2%), contrast (7.3%; 0.8-12.4%), and CNR (7.4%; 2.0-12.6).Differences between SS and DS were even smaller for the detectability index (0.7%; 0.1-2.3%). NPS and TTF curves for SS and DSacquisitions showed nearly perfect overlap for all radiation dose levels.

CONCLUSION

DS single-energy MDCT platform can precisely and accurately reconstruct datasets at different radiation dose levels from theprojection data acquired of each radiation tube by itself or in combination with the second radiation tube.


A reliable strategy to simultaneously obtain three dose levels from a single, dose-neutral, MDCT acquisition can overcome the

SSK16-06 RIS-integrated Dose Monitoring System: First Optimization Results for a Breast Screening Programon a Large Dataset of FFDM and DBT Exams


SSK16-07 Effects on Radiation Exposure and Image Quality of Abdominal CT with Attenuation-based AutomaticKilovoltage Selection


practical and ethical challenge of obtaining multiple dose levels from the same patient.

ParticipantsAndrea Nitrosi, PhD, Reggio Emilia, Italy (Presenter) Nothing to DiscloseMarco Bertolini, Reggio Emilia, Italy (Abstract Co-Author) Nothing to DiscloseCinzia Campari, Reggio Emilia, Italy (Abstract Co-Author) Nothing to DiscloseRoberto Sghedoni, PhD, Reggio Emilia, Italy (Abstract Co-Author) Nothing to DisclosePierpaolo Pattacini, Reggio Emilia, Italy (Abstract Co-Author) Nothing to DiscloseVladimiro Ginocchi, Reggio Emilia, Italy (Abstract Co-Author) Nothing to DiscloseLorenzo Ghiddi, Reggio Emilia, Italy (Abstract Co-Author) Nothing to DiscloseGiulio Tondelli, Correggio, Italy (Abstract Co-Author) Nothing to DiscloseValentina Iotti, MD, Reggio Emilia, Italy (Abstract Co-Author) Nothing to DiscloseRita Vacondio, Reggio Emilia, Italy (Abstract Co-Author) Nothing to DiscloseMauro Iori, Reggio Emilia, Italy (Abstract Co-Author) Nothing to Disclose

PURPOSE

To show how a RIS-integrated dose monitoring systems can reduce variability of acquisition settings optimizing dose-image qualityratio in a population based breast screening program (BSP).


Our Diagnostic Imaging Department (DID) adopted a RIS-PACS integrateddose monitoring system. For mammography, the averageglandular dose (AGD), compression level, breast thickness and glandularity, as well as the selected automatic exposure control(AOP) mode (for FFDM one among three with increasing dose levels labelled as "dose", "standard" and "contrast", for DBT a singledose level called "tomo" are available) are registered for each projection. The DID BSP monitors about 55,000 examinations/yearfrom eleven mammography units equally configured. To date we collected data from more than 500,000 mammographic exposuresand more than 15,000 DBT ones.. AGD dependency on the compression force and the selected AOP has been verified. Thecompression force (at least 100N) and the FFDM AOP selection ("dose" mode) were standardized among the radiographers.

RESULTS

After standardization FFDM AGD variability decreased from 60% to 28% and the overall median AGD decreased from 1.38 to 1.22mGy. For FFDM AOP dose, standard and contrast the median AGD (mGy) [25th percentile, 75th percentile] were respectively 1.18[1.06, 1.37], 1.51 [1.35, 1.77], 1.85 [1.72, 2.05] while for DBT AOP tomo were 1.61 [1.44, 1.85]. The breast compressed thicknessmedian both for FFDM and DBT was 53 mm, while the median glandularity calculated by the mammographic unit were respectively40% and 20%.

CONCLUSION

It has been verified that AGD is highly dependent on the AOP mode selectd for FFDM and on the compression force both for FFDMand DBT. The glandularity evaluation is quite different between FFDM and DBT. This element probably impacts on AGD calculations.


The iterative application of monitoring processes and integration with information systems like RIS for the qualification of imagequality-dose ratio, may improve clinical quality performance in diagnostic imaging.

ParticipantsShuTing Wang, Shenyang, China (Abstract Co-Author) Nothing to DiscloseKe Ren, MD, ShenYang, China (Abstract Co-Author) Nothing to DiscloseLong Cui, MD, PhD, Shenyang, China (Presenter) Nothing to Disclose

PURPOSE

To compare the radiation dose and image quality between standard-dose CT and a low-dose CT obtained with the combined use ofan attenuation-based automatic kilovoltage (kV) selection tool (kV Assist) and adaptive statistical iterative reconstruction (ASiR)for abdominal CT examination of adults with small or medium body size.


Sixty consecutive patients with body mass index (BMI) below 26kg/m2 underwent abdominal contrast-enhanced CT(GE DiscoveryCT750 HD). Patients were divided into two groups, Automated adaption of both tube potential and tube current in group A (n=30)and with fixed 120 kV in group B(n=30).Data of two groups were reprocessed with 50% and 30%ASiR,respectively. CTDIvol and DLPwere recorded and the effective dose(ED)was calculated. The objective image quality was assessed in both arterial phase andportal venous phase. Signal-to-noise ratio(SNR) , contrast-to-noise ratio (CNR) of various tissues were calculated. The subjectiveimage quality was assessed by two blinded and independent observers with a 5-point scale (1=non diagnostic; 5=excellent) .

RESULTS

KV Assist protocol in group A resulted in a kV-decline from 120 to 100 kV in 20patients (66.67%)and to 80 kV in10patients(33.33%). Overall CTDIvol (mGy),DLP(mGy·cm) and ED (mSv) of group A were significantly lower than in group B(21.85±7.19 vs. 36.91±8.43 mGy; 1099.48±379.72vs.1854.38±455.28 mGy·cm; 16.49±5.70vs. 27.82±6.83 mSv ;p<0.001), with adose reduction of 40.80% (15.06/36.91),40.71%(754.90/1854.38) and 40.73%(11.33/27.82), respectively. Although the noise wasslightly higher in group A ( 13.60±1.74 vs. 12.27±1.73 HU in arterial phase while 13.92±2.11vs. 12.66±2.35 HU in portal venousphase; p<0.05), the SNRs and CNRs were similar to or even higher than that of standard 120-kV protocol. No significant differences

SSK16-08 Does Body Mass Index (BMI) Outperform Body Weight as a Surrogate Parameter for Size SpecificDose Estimates (SSDE) in Adult Patients?


SSK16-09 Body Mass Index Based GSI Assist in Abdominal CT: Investigation of Radiation Dose and ImageNoise

Wednesday, Dec. 2 11:50AM - 12:00PM Location: S404AB

in subjective image quality (4.42±0.64 vs.4.67±0.48, p=0.127) were observed. The inter-observer consistency for subjective imagequality was good(k=0.71).

CONCLUSION

The kV Assist protocol was demonstrated to be applicable in clinical routine of abdominal CT examinations for adults of small ormedium body size which can reduced radiation dose while preserving image quality.


Combined use of kV Assist and ASiR allowed a significant reduction in radiation exposure while maintaining image quality in abdominalCT .

ParticipantsJohannes Boos, MD, Boston, MA (Abstract Co-Author) Nothing to DiscloseRotem S. Lanzman, MD, Duesseldorf, Germany (Abstract Co-Author) Nothing to DiscloseChristoph Schleich, Dusseldorf, Germany (Abstract Co-Author) Nothing to DisclosePatric Kroepil, MD, Duesseldorf, Germany (Abstract Co-Author) Nothing to DiscloseGerald Antoch, MD, Duesseldorf, Germany (Abstract Co-Author) Nothing to DiscloseChristoph K. Thomas, MD, Dusseldorf, Germany (Presenter) Speaker, Siemens AG

PURPOSE

Body weight has been proposed as a comprehensive alternative to surrogate size specific dose estimates (SSDE). The aim of thisstudy was to assess the value of the body mass index (BMI) in comparison to body weight as a surrogate parameter for SSDE inabdominal and chest CT of adult patients.


211 patients (83 female, 128 male, mean age 61.6±14.0 years) undergoing CT examinations of the chest (n=105) or abdomen(n=106) were included in this retrospective study. Weight and size of the patient at the time of the examinations were used tocalculate the BMI (weight/size²). Effective diameter (Deff) was assessed performing diameter measurements in the axial midvolumeCT-slice. Correlation between BMI, weight and effective diameter was calculated. SSDE were calculated based on Deff, weight andBMI.

RESULTS

Mean size, weight and BMI were 172.7±10.0cm, 80.2±19.9kg and 26.8±5.6kg/cm2, respectively. Mean lateral diameter, a.p.diameter and Deff were 35.9±4.9, 28.9±4.4 and 30.4±4.4, respectively. There was a significant correlation between BMI and Deff(r=0.82) as well as weight and Deff (r=0.82) (p<0.05 respectively). SSDE calculation based on BMI matched SSDE based on Deff(7.3±2.7mGy vs 7.3±2.7mGy), while SSDE calculation based on body weight led to a difference of 7% (7.8±4.4mGy, p>0.05). BMIshowed a better correlation with Deff than body weight for abdominal CT (r=0.87 vs 0.84) while correlation was inferior for chestCT (r=0.76 vs 0.82).

CONCLUSION

SSDE based on BMI do not differ significantly from SSDE based on diameter measurements in thoracoabdominal CT and can be usedto simplify the SSDE method. Furthermore, BMI is superior to body weight as a surrogate parameter for SSDE in abdominal CT ofadult patients.


BMI can be used as a surrogate for SSDE. Thereby, BMI can lead to relevant simplification of the SSDE method, especially in largescale register analysis.

ParticipantsChai Y. Ru III, MD, Zhengzhou, China (Presenter) Nothing to DiscloseJianbo Gao, MD, Zhengzhou, China (Abstract Co-Author) Nothing to DisclosePeijie Lv, MMed, Zhengzhou, China (Abstract Co-Author) Nothing to Disclose

PURPOSE

To investigate the radiation dose and image noise of spectral CT imaging with gemstone spectral imaging(GSI) assist in abdominalCT based on the body mass index(BMI) compared with conventional CT scan


This study received institutional review board approval, and all participants provided written informed consent. 68 patientsunderwent CT plain scan with the conventional mode of 120 kVp and enhanced CT with spectral imaging mode in arterial phase (AP)and venous phase(VP). The optimal spectral imaging parameters were automatically selected with GSI assist on. 65 keVmonochromatic images in venous phase were reconstructed and compared with plain CT images. All patients were divided into fourgroups according to BMI(group A,n=12:BMI <18.5 kg/m2; group B,n=28:BMI 18.5~23.9 kg/m2; group C,n=19:BMI 24~28.9 kg/m2;group D,n=9:BMI ≥29 kg/m2). Image noise of liver, muscle and abdominal subcutaneous fat was measured, and volume CT doseindex(CTDIvol) and effective dose(ED) were recorded among the four groups. Difference of radiation dose and image noise betweenthe two scanning modes in each group were compared using paired t-test.

RESULTS

Between the conventional mode and spectral CT with GSI assist mode for all patients, the CTDIvol and ED showed no significantdifferences(P=0.071,0.059), while the image noise of liver, muscle and fat had significant differences(all P<0.001). In group A, theCTDIvol, ED and image noise of liver ,muscle and fat for GSI assist mode were lower than conventional mode (all P<0.001). TheCTDIvol and ED had no significant difference between the two scanning mode in group B(P=0.058,0.077) and groupC(P=0.073,0.059), but higher for the GSI assist mode in group D(both P<0.001). Image noise of liver, muscle and fat in group B, Cand D for GSI assist mode were all lower than conventional CT mode(all P<0.001) except for the image noise of fat in groupD(P=0.055).

CONCLUSION

GSI assist scanning mode can reduce radiation dose in patients with BMI under 18.5 kg/m2 without sacrificing image quality and canreduce image noise in patients with BMI range between 24kg/m2 and 28.9 kg/m2 in equivalent radiation dose.


Within a certain BMI range, GSI assist scan mode can reduce radiation dose or image noise, and is recommended clinical applicationfor its easy operation.

SSK17-01 Radiation Oncology Keynote Speaker: Perspectives in Breast Cancer

Wednesday, Dec. 2 10:30AM - 10:40AM Location: S104A

SSK17-02 An Institutional Review of Radiation Doses from Radiological Imaging Procedures in Image-guidedRadiotherapy of Cancers


SSK17-03 Impact of Single Day Multidisciplinary Clinics on the Lead Time from Diagnosis to Initiation ofTreatment in Head and Neck Cancers


SSK17

ISP: Radiation Oncology (Outcomes/Quality of Life I)

Wednesday, Dec. 2 10:30AM - 12:00PM Location: S104A

RO SQ


ParticipantsMartin Colman, MD, Houston, TX (Moderator) Nothing to DiscloseJames S. Welsh, MD, MS, Batavia, IL (Moderator) Nothing to Disclose

Sub-Events

ParticipantsAnna Shapiro, MD, Syracuse, NY (Presenter) Nothing to Disclose

ParticipantsLi Zhou, PhD, Chengdu, China (Abstract Co-Author) Nothing to DiscloseYibao Zhang, Beijing, China (Abstract Co-Author) Nothing to DiscloseJun Deng, PhD, New Haven, CT (Presenter) Nothing to Disclose

PURPOSE

To systematically compare radiation doses to organs-at-risk (OARs) between planning CTs and image-guided procedures duringimage-guided radiotherapy (IGRT) of cancers.


With IRB approval, 4832 cancer patients who underwent IGRT at our institution between Sep. 2009 and Apr. 2014 were included inthis retrospective study. Their gender, age, circumference were collected as well as all the radiological imaging proceduresperformed, including computed tomography (CT), kilo-voltage portal imaging (kVPI), megavoltage portal imaging (MVPI) and kilo-voltage cone-beam computed tomography (kVCBCT). Correlations between patient's size and organ dose were first established viaMonte Carlo dose calculations in patient anatomy, and then used for patient-specific organ dose estimation. The imaging doses tobrain, lungs and red bone marrow (RBM) were analyzed.

RESULTS

A total of 142017 imaging procedures were performed on 4832 patients, 5113 of which were CT scans. Regardless of age, averageCT doses to brain, lungs and RBM were 0.5, 0.6, 0.6 cGy for males, and 0.5, 0.6, 0.6 cGy for females, accounting for 1.6%, 3.5%,2.0%, 1.6%, 4.0% and 3.3% of combined dose, respectively. Peaking at 45 cGy, kVPI contributed largest doses to brain, about 47times of CT doses. In lungs and RBM, average kVPI dose remained higher for most children but decreased below 14 cGy in adults.Unlike kVPI, average MVPI doses to OARs were less than 10 cGy, peaking at 16 cGy in RBM for eldest males. kVCBCT doses weregenerally 0-8 cGy except for males of 51 years and older who received largest number of scans in pelvis.

CONCLUSION

While CT scans deposited a small portion of radiation doses to cancer patients, image-guided procedures employed in IGRT cancontribute up to 50 cGy of cumulative imaging doses to brain, 30 cGy to lungs and 40 cGy to RBM in pediatric patients. This studyindicated a pressing need for personalized imaging protocol to maximize clinical benefits of imaging procedures while reducingimaging doses and associated cancer risks.


(dose comparison among imaging procedures) This study reveals a strong need for personalized imaging protocol to maximize clinicalbenefits of imaging procedures while reducing imaging doses and associated cancer risks.

ParticipantsRaju Vaddepally, Oak Brook, IL (Presenter) Nothing to Disclose

ABSTRACT

Purpose/Objective(s): We evaluated the impact of single day multidisciplinary clinics (MDC) on the lead time from diagnosis totreatment in head and neck cancers compared with matching patients prior to the implementation of MDC. We also wanted toinvestigate the relationship of demographic factors to the lead time.Materials/Methods: We retrospectively analyzed clinical anddemographical variables of 310 patient's records collected from head and neck cancer tumor registry at St. Joseph Mercy Hospital,Ann Arbor, from 2007 to 2013. We had 170 cases with in the MDC period compared to 140 prior to the MDC.Results: We excluded60 cases from our analysis because of missing data; no date of biopsy (N=5), no documentation of first treatment date (N=42)

SSK17-05 A Review of Studies Using Self-reported Measures of Sexual Function among Female Cancer PatientsTreated with Radiation Therapy, 2008-2014


SSK17-06 The Impact of Weight Loss on Set-up Accuracy with Patients Receiving Head and Neck CancerRadiation Therapy


SSK17-07 Technology Meets Quality for Physician Collaboration in Oncology Peer Review


and tumor resected on the same day of biopsy (N=22). This left 129 cases (76%) in the MDC period and 112 cases (80%) in thePre-MDC period. Mean age was 63 in both the groups. Frequencies of other demographic factors include males (76% vs 79%),Caucasians (91% vs 88%), married (66% vs 62%) and insurance as Medicare (57% vs 50%), median distance from clinic (22 milesvs 17), in the MDC vs Pre-MDC groups respectively. Most of the cancers were squamous cell carcinomas (88% vs 83%), however,we had more stage 4 disease in MDC (56%) when compared to the Pre-MDC group (41%). To compare the two groups, afteradjusting for demographic variables and an interaction between stage and site, we fit a generalized linear regression model. Therewas no difference in the median number of days from biopsy to definitive treatment between the two groups, (35 MDC vs 33.5 inpre-MDC, p = 0.14. The average number of days from biopsy to definitive treatment was 1.13 times longer, for the MDC group (95%CI: 0.96 to 1.32). Marital status was the only variable statistically significantly related to lead time (p = 0.04). Time to definitivetreatment was 0.83 (95% CI: 0.70 to 0.99) times shorter, on average for married vs unmarried patients in both the groups. Posthoc analysis was also done to investigate the association between MDC and time to first radiation dose, where radiation was thefirst treatment. There were only 78 cases that met these criteria, Pre-MDC (N=37) and MDC (N=41). The negative binomialregression model showed no association of MDC with time to first radiation treatment (median time in days was, 40 in pre-MDC vs38 in MDC). Time to radiation treatment was 0.91 (95% CI: 0.74 to 1.10) times shorter in the MDC when compared to the pre-MDCgroup. Conclusion: There was no significant difference in lead time with single day MDC compared to patients Pre-MDC in head &neck cancer patients. However, patients in the MDC group had more advanced cancer, which could reflect more complex work-upand management, resulting in longer lead time. Interestingly, marital status was associated with decrease in lead time in marriedcompared to unmarried patients, in both the groups.

ParticipantsAnuja Jhingran, MD, Houston, TX (Presenter) Nothing to Disclose

ABSTRACT

Purpose/Objective(s): A systematic review was conducted to identify and characterize self-reported sexual function (SF) measuresadministered to women who had received radiation therapy (RT) for cancer.Materials/Methods: Using 2009 PRISMA guidelines, wesearched electronic bibliographic databases for quantitative studies published January 2008-September 2014 that used a self-reported measure of SF, or a quality of life (QOL) measure that contained at least one item pertaining to SF. Of these studies, weselected articles that reported the percentage of females who had received any form of RT.Results: Of 1,487 articles initiallyidentified, 83 met inclusion criteria. The studies originated in 28 different countries with 23% from the U.S.A. Most studies focusedon women treated for breast, gynecologic, or colorectal cancer, with the percent of women having received RT ranging from 7% to100%. Only 19 articles (23%) provided information about radiation dose, number of fractions, field, or type of RT equipment SFwas assessed with 27 unique self-reported measure, the most common being the EORTC QLQ modules (considered as one measure),the Female Sexual Function Inventory, and the Sexual Function Vaginal Changes Questionnaire. Of the 32 studies designed tocompare SF by treatment modality, one-third found no statistically significant difference between RT and other modalities, and 28%found worse SF associated with RT. Only 4 studies reported on interventions to improve SF.Conclusion: The paucity of RTinformation in the reviewed articles, and the large number of measures used to assess SF limit comparative analysis. Needed areintervention studies with common metrics, preferably dedicated SF measures developed with cancer patients treated with RT. Thissystematic review will assist radiation oncologists select SF measures and encourage assessment of this quality of life domain inpatient care.

ParticipantsSayyad Y. Zia, MA, MD, New York, NY (Presenter) Nothing to DiscloseAwais Mirza, Mineola, NY (Abstract Co-Author) Nothing to DiscloseUmut Ozbek, New York, NY (Abstract Co-Author) Nothing to DiscloseRen-Dih Sheu, PhD, New York, NY (Abstract Co-Author) Nothing to DiscloseVishal Gupta, MD, Sacramento, CA (Abstract Co-Author) Nothing to DiscloseRichard L. Bakst, MD, New York, NY (Abstract Co-Author) Nothing to Disclose

ABSTRACT

Purpose/Objective(s): Patients receiving radiation therapy for head and neck cancers often experience severe weight loss and insome cases require re-planning. The purpose of this study was to evaluate whether we can determine at what point patients dailyshifts vary greatly in relation to their specific weight loss to ensure the safe delivery of radiation therapy to ourpatients.Materials/Methods: 99 consecutive patients with head and neck cancers were treated with radiation therapy (+/-chemotherapy) at our institution. Patient and disease characteristics: median age 59 (41-94), 14% female, 86% male, 3% Stage 0,10% Stage I, 12% Stage II, 15% Stage III, 60% Stage IV. Weight loss was measured and recorded during weekly on treatmentvisits. KV imaging was performed daily to ensure setup accuracy. All shifts were recorded on a daily basis to include AP, LR, and SIshift. Spearman correlation coefficients were used in statistical analysis.Results: The mean weight loss during treatment in ourcohort was 13.6kgs (+2.4kgs to - 24.9kgs). Stage of disease was found to correlate with percent weight loss (p=0.040). Meanweight loss was found to increase with advanced stage disease (Table 1).MEAN WEIGHT LOSSStageMean WeightLoss(kg)01.81I4.26II6.58III6.28IV7.75In regards to treatment, there was no statistical correlation between treatment beingadjuvant or definitive with regards to percentage weight change (p=0.56). The largest PA (posterior-anterior) shift (p=.309), SI(superior-inferior) shift (p=.517), LR (left-right) shift (p=.303) compared to the largest shift (p=.247) were trended against weightloss and found not to be statistically significant. Conclusion: Our study demonstrates that despite weight loss of head and neckcancer patients, there was no significant correlation with setup inaccuracy. Increasing stage was found to be predictive of anincrease in percent weight change. This study suggests that most patients undergoing head and neck radiation therapy will have areliable set-up when properly immobilized despite weight loss. Further, this study highlights the importance of daily KV imaging andclose monitoring of patients weight in head and neck cancer patients.

SSK17-08 Proton Radiation Therapy for Incurable Head and Neck Disease by the Palliative QUAD Shot Regimen


SSK17-09 Patterns of Local and Distant Recurrence Based on MAP Kinase Pathway Mutations in Patients withStage III Melanoma Treated with Lymph Node Dissection and Adjuvant Radiation Therapy

Wednesday, Dec. 2 11:50AM - 12:00PM Location: S104A

ParticipantsDawn Henrich, San Jose, CA (Presenter) Employee, iCAD, Inc; Stockholder, iCAD, Inc; Ajay Bhatnagar, MD, Pittsburgh, PA (Abstract Co-Author) Consultant, iCAD, IncBridget Krueger, San Jose, CA (Abstract Co-Author) Employee, iCAD, IncKamal Gogineni, San Jose, CA (Abstract Co-Author) Employee, iCAD, Inc

ABSTRACT

Purpose/Objective(s): Surface electronic brachytherapy is becoming recognized for treatment of non-melanoma skin cancer(NMSC). Radiation Oncologists providing these treatments may not have peer-to-peer collaboration available. This abstract willdemonstrate feasibility in performing peer review within multiple non-affiliated organizations using a cloud-based platform toincrease quality and safety.Materials/Methods: The oncology system stores patient specific clinical and dosimetric data forelectronic brachytherapy and was utilized for multi-fraction treatment across several facilities. A total of 37,000 consecutivetreatments were captured over a period of 2.5 years. The oncology platform is used to facilitate workflow management anddocumentation in a process structured environment. Mandatory fields throughout the care path allow consistent data to maximizecomprehensive peer reviews. The cloud-based infrastructure permitted quick access to pertinent chart details across multiple non-affiliated locations to streamline the peer review method.Evaluation elements specific to surface electronic brachytherapy weredetermined at onset. These included a variety of specifications regarding clinical presentation, diagnosis including pathology,informed consent, radiation prescription including dose fractionation scheme, treatment delivery parameters and presence ofappropriate clinical documentation. An independent Radiation Oncologist was chosen to review 2 patient charts per month at eachlocation during the validation process between July-December 2014.Results: Peer Review of 69 unique NMSC lesions was completedin 65 patients with a mean age of 78 years (Range 56–96). Pathologic histology presented with Basal Cell, Squamous Cell,Carcinoma in Situ, and Basosquamous in anatomic locations throughout the face, trunk, and scalp (63%, 31%, and 6%,respectively.) The peer reviewed patients were supervised by 22 Radiation Oncologists located across 11 unique locations.A doseprescription was present in 100% of patient charts which varied between 500cGy, 400cGy, and 450cGy per fraction (84%, 13%,and 3% respectively). These were prescribed at depths of 2, 3, and 4 mm with 55% most commonly prescribed at 2 mm. Additionaldata fields such as lesion size, cone size, and cutout type assisted in determining appropriateness of treatment parameters. Appropriateness of care was satisfactory in all patient charts evaluated.Conclusion: A cloud-based management platform enables asingle Radiation Oncologist to remotely complete peer reviews effectively across multiple non-affiliated locations. The concept ofutilizing data systems to complete peer review for surface electronic brachytherapy is feasible and should be introduced in thebroader oncology community for data capture and predictive analytics to improve patient care.

ParticipantsStanley Gutiontov, MD, Chicago, IL (Presenter) Nothing to Disclose

ABSTRACT

Purpose/Objective(s): To report our institutional experience of palliative proton radiotherapy (RT) for cancers in the head and neckwith the QUAD SHOT regimen.Materials/Methods: Seventeen patients completed at least 1 cycle of palliative RT to the head andneck with proton therapy for incurable primary or metastatic disease based on the RTOG 85-02 QUAD SHOT regimen (370 CGE twicedaily over 2 consecutive days at 2 to 3 week intervals up to a total dose of 4400 CGE) between July 2013 and January 2015 at ourcenter; two were lost to follow-up. In the remaining fifteen patients, we defined palliation as relief of the presenting symptom(s)or tumor response by clinical exam or imaging. Overall survival (OS) was estimated by the Kaplan-Meier (KM) method. TheSpearman rho test was used to examine the correlation between various clinical factors and palliative response. Toxicity wasscored using the NCI CTCAE v4.0.Results: Median patient age was 70 years (range 54 to 89). 66% were male and 34% werefemale. The most common histology was squamous cell carcinoma (66%), followed by adenocarcinoma of the lung metastatic to thehead and neck (13%), non-anaplastic thyroid carcinoma (7%), mucosal melanoma (7%), and adenocarcinoma (7%). Primary orrecurrent AJCC stage was I (7%), II (13%), III (0%), IV (67%), and unknown (13%). The stage I patient also had metastaticSCLC. Five patients (33%) had a history of surgical resection at the primary disease site, eleven patients (73%) had previouslyreceived systemic chemotherapy, and ten patients (66%) had received significant prior RT at the palliative site (median dose 66Gy; range, 21 to 75 Gy). Three patients had received two prior courses of RT to the site. KPS was =70 in all patients. The mostcommon presenting symptoms were visual changes (16%), dysphagia/odynophagia (16%), pain (12%), and/or epistaxis (12%). Seven patients (47%) completed three QUAD SHOT cycles, and six patients (40%) received systemic therapy, typically targetedagents, concurrently. Palliative response was observed in 73% of patients. Median OS was 4.17 months (range, 0.57-17.0). NoGrade 3 or higher acute toxicities were observed. One patient, who had received two prior courses of RT to the site, developed aGrade 2 dermatitis. The most common toxicity was Grade 1 fatigue (27%). By the log-rank test, palliative response (p=0.018) wasassociated with improved OS. Using bivariate analysis, palliative response was correlated with increasing number of QUAD SHOTcycles (p=0.017) but not with KPS, histology, or concurrent chemotherapy. Conclusion: Delivery of the QUAD SHOT regimen byproton radiotherapy for patients with loco-regionally advanced or metastatic disease in the head and neck provides excellent ratesof palliative response with no Grade 3 or higher acute toxicity. The minimal toxicity profile in these heavily pre-irradiated patients isencouraging and warrants further study.

ParticipantsPriyanka Chablani, BA,MS, Columbus, OH (Presenter) Nothing to DiscloseSteve Walston, DO, Columbus, OH (Abstract Co-Author) Nothing to DiscloseErinn Hade, PhD, Columbus, OH (Abstract Co-Author) Nothing to DiscloseSara Peters, MD,PhD, Columbus, OH (Abstract Co-Author) Nothing to DiscloseTerence M. Williams, MD, PhD, Columbus, OH (Abstract Co-Author) Nothing to DiscloseEvan J. Wuthrick, MD, Columbus, OH (Abstract Co-Author) Nothing to Disclose

PURPOSE

The role of adjuvant radiation therapy (ART) after lymph node dissection (LND) in pts with Stage III melanoma is controversial.

Recently, different sub-groups of melanoma have emerged based on the presence of BRAF and NRAS driver mutations in the MAPKinase pathway. We sought to determine clinical outcomes after LND and ART on the basis of BRAF, NRAS, and MAPK-wild-type(wt) status.


We reviewed the records of patients (pts) treated with LND followed by ART at our institution from 2006 to mid-2014. 65 pts metour study criteria. We collected information on demographic, pathologic, and treatment-related variables from medical records. Wetested melanoma tissue samples from all pts for BRAF/NRAS mutations using PCR-based genetic assays. Loco-regional and distantrecurrences were assessed using follow-up imaging and exam findings. We examined the association of variables collected withclinical outcomes using Kaplan and Meier methods and Cox proportional hazards models.

RESULTS

Of the 65 pts, 42 (65%) were male and the median age was 57 yrs (range 22 - 87). 19 pts (29%) received LND and ART to thehead and neck, 28 (43%) to the axilla, and 18 (28%) to the groin. Pts received external beam RT with the majority receiving 30Gy/5 fractions (61%) or 48 Gy/20 fractions (26%). 32 pts (49%) were BRAF-positive, 33 pts (51%) were BRAF-negative. Of the 33BRAF-negative pts, 15 pts (23%) had NRAS mutations, 18 pts (28%) were MAPK-wt. Median follow up time was 1.6 years (0.2-7.8). Presence of BRAF mutation was significantly associated with local-regional recurrence (HR: 4.3; 95% CI 0.9-20.0; p = 0.06).At 2-yr follow-up, 33% of BRAF+ pts failed loco-regionally, compared to 7% of BRAF- pts. There were a total of 11 loco-regionalfailures.Presence of BRAF mutation was not significantly associated with distant failure (aHR: 0.75; 95% CI 0.4-1.4; p = 0.34). At2-yr follow-up, 54% of BRAF+ pts had distant failure, compared to 65% of BRAF- pts. There were a total of 37 distant failures.

CONCLUSION

BRAF-positive pts had significantly increased rates of loco-regional failure but similar rates of distant failure compared to BRAF-negative pts after LND and ART for Stage III Melanoma.


BRAF-positive pts may derive less loco-regional control than BRAF-negative pts from ART after LND for Stage III melanoma;adjuvant immunotherapy or targeted therapy may be better options for these pts.

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QS125-ED-WEB1

Encouraging Squeakier Wheels: Implementation and Experience with an Image Quality AssuranceReporting Tool

Station #1

QS127-ED-WEB2

1-800-Imaging Pilot Project: Building Partnerships between Primary Care and Medical Imaging

Station #2

QSE-WEB

Quality Storyboards Wednesday Poster Discussions

Wednesday, Dec. 2 12:45PM - 1:15PM Location: QS Community, Learning Center


Participants

Sub-Events

ParticipantsJustin Cramer, MD, Salt Lake City, UT (Presenter) Nothing to DiscloseMatthew B. Morgan, MD, Sandy, UT (Abstract Co-Author) Consultant, Reed ElsevierTony Jones, Salt Lake City, UT (Abstract Co-Author) Nothing to DiscloseGeorge Milliner, Salt Lake City, UT (Abstract Co-Author) Nothing to DiscloseUlrich A. Rassner, MD, Salt Lake City, UT (Abstract Co-Author) Speaker, Siemens AG

PURPOSE

Identifying and fixing image quality issues is fundamental to the practice of radiology. Nevertheless, it is difficult to get busyradiologists to consistently report issues. The more a reporting system disturbs workflow, the more unlikely it is for reporting tooccur. We sought to replace a cumbersome process of image quality reporting with a more streamlined tool integrated into thePACS system.

METHODS

The previously existing system of image quality reporting consisted of a shared folder in PACS. Radiologists would add a study tothe folder, and then have to get out of the study to add a description. Alternatively, issues were often reported verbally andlacked important details. "I had a study last week that looked funny but I can't remember the name" was a typical scenario. Theneed for an improved system of image quality reporting was identified. Several meetings were held to identify functionalrequirements for a new image quality assurance (QA) tool. Attendees included a department software engineer, PACS administrator,the director of radiology informatics, the director of clinical services, a medical physicist, and radiologists involved in image qualityimprovement. Key requirements included integration with the PACS right-click context menu, the absence of required fields, andoptions to categorize image quality issues. Additionally, the tool would automatically capture information about the study includingpatient demographics, the study series and image number, which technologist performed the study, modality name and location,date and time of submission, and date and time of the study. (See Fig. 1) Requirements were also specified for an administrativedashboard. These included a listing of all outstanding issues, the ability to display issues by modality, sub-categorize issues, applya status, and take notes. A department software engineer implemented the user tool as an HTML form launched from PACS, andthe administrative dashboard as an HTML page accessible to privileged users. When the tool went live, a presentation was given tofaculty and residents as well as an e-mail was sent to the department describing usage. The e-mail also detailed the administrativeprocess for addressing issues.

RESULTS

There were a total of 97 issue submissions in the 12 months prior to the image QA tool implementation for an average of 8.1 issuesper month. Only a few users submitted the majority of these. In the four months following implementation, 381 submissions werereceived, for an average of 95.25 per month. 38 different users submitted issues. A number of quality issues were identified thatwere present well before the tool implementation. These included differing protocols on different scanners, incorrect servicing of anx-ray machine, recurring issues across technologists that were addressed in staff meetings, and incorrect calculation of deviationindices. Finally, the image QA tool also offers an option for "Praise", where radiologists can compliment technologists for outstandingwork. Technologists receive a $5 gift card for any praise. This has predictably met with a positive response and boosted morale.

CONCLUSION

We implemented a tool for submitting image quality issues that was integrated into our PACS system and minimally disruptedradiologist workflow. The result was a dramatic increase in both the number of submitted issues and the number of participatingradiologists. Finally, the administrative tool for tracking and addressing issues has facilitated translation into actual image qualityimprovement.

ParticipantsKaren Weiser, MBA, Toronto, ON (Presenter) Nothing to DiscloseLilly Whitham, Toronto, ON (Abstract Co-Author) Nothing to Disclose

PURPOSE

The 1-800 Imaging call centre was designed to improve integration between primary care providers in the community (PCPs) andmedical imaging within a tertiary sub-specialized environment. It is a virtual hub that gives PCPs a direct point of contact within acomplex, academic medical imaging department, to facilitate real-time consultation with a sub-specialized radiologist and toescalate urgent imaging requests. The purpose of 1-800 Imaging pilot project is to:• Reduce inappropriate imaging orders • Reduceemergency department visits• Improve patient experience of care• Improve provider experience during transitions to radiologyThepilot was designed according to the Institute for Healthcare Improvement principles of the "Triple Aim" to improve patient/providerexperience of care, better population health, and lower per-capita costs of care.

QS129-ED-WEB3

Macro Critical: Standardizing Documentation of Radiology Critical Test Results

Station #3

QS008-EB-WEB

The Discrepancy Meeting is Dead, Long Live the Educational Cases Meeting: How to Start and Run aSuccessful Governance Meeting Addressing Radiological Error in the Largest UK Hospital Trust in theUK

METHODS

The call centre partnered with an existing program that provides navigational and consultation services through a virtualinterprofessional health team to a group of 60 community PCPs. It is staffed during business hours by an experienced clerical staffand supported by an on-call radiologist. The team implemented a customized IT solution to support the call centre, to record andmanage cases. 1-800 Imaging offers the following services:1. Appropriateness Consult: Support for PCPs in selecting the mostappropriate imaging when unsure which test is indicated for their patient2. Radiology Consult: A second opinion on images, reports,or recommendations from subspecialized radiologist3. Urgent Imaging: Access to urgent imaging for patients with acute symptomswithout visiting the emergency department4. Urgent Reporting: Expedited reports from a radiologist5. General InformationalRequestsAt the conclusion of each call, PCPs were sent a brief survey to rate their satisfaction with the service.

RESULTS

During the pilot period from May 1, 2014 to March 31, 2015, the following results were found:?227 calls - 103 requests for urgentimaging- 40 appropriateness consults- 10 radiology consultations/second opinions- 7 requests for expedited reports- 67 requestsfor information/other?36 unique users accessed the call centre (60% of pilot audience) ?22 users accessed the call centre multipletimes (61% of callers) A post-call survey was completed following 42 calls; 100% of respondents indicated that they were satisfiedwith the service and 100% stated that they would recommend the call centre to their colleagues. The project had limited ability toreport conclusively on patient outcomes due to anecdotal data collection regarding appropriateness consults and emergencydepartment visits; however, the pilot group perceived that at least 40 emergency department visits were avoided by accessing thecall centre. Additionally, the 40 appropriateness consultations supported callers in ordering imaging that was most appropriate fortheir patients' specific indications.

CONCLUSION

The 1-800 Imaging pilot launched and operationalized a successful call centre for PCPs previously unable to navigate a complexacademic imaging department. The project illustrates that PCPs value conversations with Radiologists to gain clinical insights andvalidation. One of the greatest challenges was reconciling clinical appropriateness and urgency with existing wait lists for imaging.Furthermore, there was a limited ability to report conclusively on patient outcomes related to appropriateness consults andemergency department visits. Despite limited impact data, the call centre service will be maintained because of the value itprovided to the PCPs. As the service expands and regional models are contemplated, clear evidence-based guidelines will beintegrated to ensure appropriate, equitable, and efficient use of imaging resources.

ParticipantsLindsay Griffin, MD, New York, NY (Presenter) Nothing to DiscloseJoseph J. Sanger, MD, New York, NY (Abstract Co-Author) Nothing to DiscloseDana Ostrow, New York, NY (Abstract Co-Author) Nothing to DiscloseDanny C. Kim, MD, White Plains, NY (Abstract Co-Author) Nothing to Disclose

PURPOSE

One of the Joint Commission's 2015 National Patient Safety Goals is "get important test results to the right staff person on time" bydeveloping procedures to identify, manage, and evaluate the definition and recognition of critical results, by whom and to whomcritical results are reported, and acceptable length of time between the availability and reporting of critical results. Radiologicalstudies often diagnose critical test results. There is under-reporting of critical test results and variable documentation of thecommunication between radiologist and referring clinician. Manual entry of critical results into a separate database outside of theradiology reporting program may contribute to these gaps. Our goal was two-fold: 1) standardize the documentation of radiologycritical test results in the radiology report through implementation of a standardized macro for use in reporting of any criticalradiology result and 2) automate record-keeping of the number of critical test results for compliance.

METHODS

We developed a standardized macro sentence that is directly inserted into the radiology report, with fill-in categories for the criticaltest result, the name of clinician notified, the date and time of communication, and read-back confirmation. The study is thenautomatically entered into a database which aggregates critical test result submissions. The selectable list of 35 critical test resultswas taken directly from departmental policies. This initiative was shared with the department at leadership and staff meetings andthrough department-wide email correspondence.

RESULTS

This is a retrospective review of radiology reports submitted to the critical test result database in the Department of Radiology from1/1/2014 - 3/31/2015. The standardized critical results macro was introduced on 12/15/2014. A total of 332 studies logged beforeand 167 studies logged after implementation of the macro were analyzed. The standardized macro was used in 58% (97) of criticaltest results logged after 12/15/2014. After the intervention, an average of 53 critical test results were reported per month ascompared to 28 per month prior to the macro (T-test p<0.001). When the macro was used, complete reporting (critical test result,notified clinician name, date and time, and read back confirmation) increased from 35% to 100% (p < 0.0001 overall and for eachdetail independently). In the sections that diagnosed the majority of critical test results, chest and abdomen, the macro was usedin 82% of critical result cases logged and completeness of reporting increased from 47% to 100% (p<0.001). The average time toreport critical test results did not change after the intervention, as expected.

CONCLUSION

Standardizing and simplifying the process of reporting critical test results increases the frequency of recording critical test resultsand the quality and completeness of documentation. Continued efforts to increase utilization of the macro are necessary.Exploration of other opportunities to utilize information technology to improve ease of reporting critical results, including automatedinsertion of clinician contact information, date, and time, would be beneficial.

Hardcopy Backboard

ParticipantsOliver Hulson, MBChB, Leeds, United Kingdom (Presenter) Nothing to DiscloseJon Smith, FRCR, Leeds, United Kingdom (Abstract Co-Author) Nothing to DiscloseCatherine Parchment-Smith, Wakefield, United Kingdom (Abstract Co-Author) Nothing to Disclose

PURPOSE

The discrepancy meeting has traditionally been a forum in the UK where blame was attributed to an individual for a certain practiseor action which had led to subsatisfactory patient care or outcomes. Individuals understandably felt singled out by such anapproach, and therefore attendance and staff morale were at an all time low, with less than a quarter of the workforce attendingthe meeting regularly.Guidance set by the Royal College of Radiologists (RCR) states that consultant radiologists must attend aminimum of 3 meetings a year. It was clear that the meeting would require a significant overhaul if this target was to be met.

METHODS

The meeting in its current guise was laid to rest, to be replaced by the 'educational cases' meeting, a forum in which colleaguescan discuss interesting cases, those in which a false positive or false negative observation may have been made, and also anopportunity to celebrate good radiological practise. A standardised approach to the meeting was formulated and a presentationtemplate provided to ensure case contribution was as straightforward as possible. In addition, in order to improve the variety ofcases provided, a departmental standard was introduced, stipulating that each consultant contribute at least one case per year. Inorder to avoid the perceived blame and 'finger pointing' culture, we set about to standardise the notification of any possiblediscrepancy to all those involved, prior to the meeting. This was essential, to facilitate self-reflection (required by the RCR and GMCas part of the revalidation process) and also ensure that those individuals were made aware prior to the case being presented atthe meeting itself. Subspeciality interest groups (eg. paediatric radiology, vascular intervention and musculoskeletal radiology) wereinvited to provide focussed teaching sessions alongside the educational case presentations. This provided an expert opinion onthose cases in which a difference of opinion had occurred, whilst also providing useful and well-received teaching to the group as awhole.By providing breakfast, lunch and refreshments, the professional group felt valued, and the meeting has become a welcomerespite from the high-pressure clinical environment. In addition, invited speakers, including clinical colleagues outside of radiology,and also eminent speakers from outside of the institution have also proved a significant success. Finally, use of interactive votingsoftware encourages audience participation in the meeting, and also provides a record of results from questions related not only tothe case in point, but also management and training issues that may have been raised in this regard. It has led to the meetingbecoming a vital and interactive forum for issues beyond that of a simple discrepancy. The RCR suggested 'grading' errors for suchmeetings, based on severity and potential risk to the patient, a recommendation we chose to ignore. This again serves to highlightthe meeting as a forum for discussion and learning, and not an arena in which to attribute blame. The college has since rescindedthis advice.

RESULTS

With the rebranding and standardised approach, attendance has increased significantly year on year and the meeting has gonefrom strength to strength. Attendances at the previous 'discrepancy' meeting were usually in the order of 10 to 15 individuals, for aconsultant body of 65. The past three years has seen attendances of over 80% of the workforce, including consultants, trainees,and allied health professionals. Encouraging consultants to contribute at least 1 case each per year (and present an audit every 5years) ensures equitability and provides a huge case variety, highlighting interesting topics for discussion from each subspecialty.The interactive voting implemented in the meeting has been particularly well received, and has since seen a 'spin off' in the form ofan interactive teaching case taken from the meeting, loading each time one logs in to PACS.

CONCLUSION

In conclusion, the discrepancy meeting was not fit for purpose and ultimately lacked direction, leading to low morale and motivationamongst the workforce. By investing considerable time and effort in the rebranding of what has now become the 'educational cases'meeting, the success has been beyond what was initially expected.In order to provide such a meeting, one must first takeownership and encourage colleagues to do the same. A standardised format not only aids in meeting planning but also allows thetarget audience to know what to expect, and contribute appropriately. Invited speakers, interactive voting and subspecialtyteaching sessions have been particularly well-received.Finally, by changing the emphasis of the meeting from attributing blame tosharing difficult cases, highlighting potential difficulties and celebrating successes, it is hoped that you may see a similar resurgenceand renewed energy for your meeting.

SPHA41A Introduction

SPHA41B How Your Radiology Group's Big Data can Leverage Your Hospital's Success

SPHA41C Practical Techniques for Leading Change in Radiology

SPHA41D Healthcare Economics: Market Trends and Transformation

SPHA41E Question and Answer 1

SPHA41

Hospital Administrator's Symposium

Wednesday, Dec. 2 1:30PM - 4:50PM Location: S103AB

HP LM SQ


ParticipantsJonathan W. Berlin, MD, Evanston, IL (Moderator) Nothing to Disclose

LEARNING OBJECTIVES

1) Describe possible future health payment and delivery changes and their relationship to radiology. 2) Consider practicaltechniques for leading change in radiology. 3) Understand methods of radiology data analysis that may be helpful to a hospital. 4)Consider how the principles of high reliability can improve radiology quality. 5) Contemplate the benefits of radiology integration inthe era of population health. 6) Familiarize themselves with the 2017 CMS mandate for decision support regarding advancedimaging.

ABSTRACT

This program is geared toward physicians, non-physician healthcare providers, and administrators. Vendors will also find it helpful.The session will be comprised of six speakers, each speaking for 30 minutes. There are two scheduled question and answer periodswith ample opportunity for audience discussion if desired. Speakers are a mix of physicians and administrators, and topics aredesigned to address current strategic planning and economic issues pertinent to radiology, including leadership, the levaging of bigdata, radiology quality, future healthcare payment and delivery, radiology integration and population health management, and the2017 CMS mandate for pre-order decision support.

URL

Sub-Events

ParticipantsJonathan W. Berlin, MD, Evanston, IL (Presenter) Nothing to Disclose

LEARNING OBJECTIVES


ParticipantsT. Scott Law, Carmel, IN (Presenter) Founder, Zotec Partners; CEO, Zotec Partners

LEARNING OBJECTIVES


ParticipantsFrank J. Lexa, MD, Philadelphia, PA (Presenter) Nothing to Disclose

LEARNING OBJECTIVES


ParticipantsTom E. Szostak, Tustin, CA (Presenter) Employee, Toshiba Corporation

LEARNING OBJECTIVES


ABSTRACT

URL

ParticipantsT. Scott Law, Carmel, IN (Presenter) Founder, Zotec Partners; CEO, Zotec PartnersFrank J. Lexa, MD, Philadelphia, PA (Presenter) Nothing to Disclose

SPHA41F Radiology Integration: How and Why in the Era of Population Health Management

SPHA41G The 2017 Mandate for Pre-order Decision Support: What Does It Mean and Why Is It Significant?

SPHA41H Question and Answer 2

LEARNING OBJECTIVES


ParticipantsJohn P. Anastos, DO, Park Ridge, IL (Presenter) Nothing to Disclose

LEARNING OBJECTIVES


ParticipantsMark D. Hiatt, MD, MBA, Salt Lake City, UT, ([email protected]) (Presenter) Medical Director, Regence BlueCross BlueShield;Board Member, RadSite ; Former Officer, HealthHelp, LLC

LEARNING OBJECTIVES


ABSTRACT

View abstract under main course title.

ParticipantsJohn P. Anastos, DO, Park Ridge, IL (Presenter) Nothing to DiscloseMark D. Hiatt, MD, MBA, Salt Lake City, UT, ([email protected]) (Presenter) Medical Director, Regence BlueCross BlueShield;Board Member, RadSite ; Former Officer, HealthHelp, LLC

LEARNING OBJECTIVES


RCC44

Monitoring Radiation Exposure: Standards, Tools and IHE REM

Wednesday, Dec. 2 2:30PM - 4:00PM Location: S501ABC

IN SQ


ParticipantsKevin O'Donnell, Vernon Hills, IL (Moderator) Employee, Toshiba Corporation; Kevin O'Donnell, Vernon Hills, IL (Presenter) Employee, Toshiba Corporation; Michael F. McNitt-Gray, PhD, Los Angeles, CA (Presenter) Institutional research agreement, Siemens AG; Research support,Siemens AG; ; ; ; ; William W. Boonn, MD, Penn Valley, PA, ([email protected]) (Presenter) Founder, Montage Healthcare Solutions, Inc; President,Montage Healthcare Solutions, Inc; Shareholder, Montage Healthcare Solutions, Inc; Shareholder, Nuance Communications, Inc;Shareholder, Merge Healthcare Incorporated

LEARNING OBJECTIVES

1) Learn about key radiation exposure metrics, such as CTDI, and how to interpret them. 2) Learn about radiation exposuremonitoring methods and tools including 2a) Capturing dose information with the DICOM Radiation Dose SR (RDSR) standard. 2b)Managing RDSR objects with the IHE Radiation Exposure Monitoring (REM) Profile. 2c) Integrating 'CT dose screens' from legacysystems into RDSR. 2d) Pre-scan dose pop-ups on the CT console defined by the MITA Dose Check standard and AAPM guidanceon their use. 3) Learn how to specify the above features when purchasing and integrating Radiology Systems. 9) Learn aboutcomponents of a dose management program such as protocol optimization. 4) Participation in the ACR Dose Registry, and reportingrequirements such as California SB-1237.

Active Handout:Michael F. McNitt-Gray

http://abstract.rsna.org/uploads/2015/11034700/RCC44 RSNA2015_RCC44_Monitoring_Radiation_Dose_mmg_handout.pdf

Honored Educators


William W. Boonn, MD - 2012 Honored Educator

SSM05-01 Dual Energy Pulmonary CT Angiography with a 3rd Generation Dual Source CT System Using 5.4g ofIodine in Comparison to a Second Generation DSCT Scan with 32g of Iodine: A Feasibility Study

Wednesday, Dec. 2 3:00PM - 3:10PM Location: S404CD

SSM05-02 Clinical Severity of Chronic Thromboembolic Pulmonary Hypertension: Assessment on Lung PerfusedBlood Volume Images Acquired by Dual Energy CT


SSM05

Chest (Vascular/ Radiation Dose Reduction)


CH CT SQ


ParticipantsEdith M. Marom, MD, Ramat Gan, Israel (Moderator) Nothing to DiscloseBrett W. Carter, MD, Houston, TX (Moderator) Author, Reed Elsevier; Consultant, St. Jude Medical, Inc; ;

Sub-Events


ParticipantsMathias Meyer, Mannheim, Germany (Presenter) Speaker, Siemens AG; Speaker, Bracco GroupHolger Haubenreisser, Mannheim, Germany (Abstract Co-Author) Speaker, Siemens AG; Speaker, Bayer AGSonja Sudarski, MD, Mannheim, Germany (Abstract Co-Author) Nothing to DiscloseStefan O. Schoenberg, MD, PhD, Mannheim , Germany (Abstract Co-Author) Institutional research agreement, Siemens AGThomas Henzler, MD, Mannheim, Germany (Abstract Co-Author) Nothing to Disclose

PURPOSE

To compare objective and subjective image quality between a dual-energy (DE) CT pulmonary angiography (CTPA) protocol using a5.4g of iodine load versus standard CTPA protocols using a 32g iodine load.


This prospective IRB-approved study included 150 in-patients/emergency patients with suspected pulmonary embolism (78 male;mean age 65±17 years). Fifty patients who were examined on a 3rd generation dual-source CT (DSCT) with a newly optimized DECTPA protocol had chronic renal insufficiency (estimated glomerular filtration rate <60ml/min/1.73mSquared) and thus received alow contrast media injection of 5.4g iodine. Each of these fifty patients were either examined with a standard CTPA protocol or astandard DE CTPA receiving an iodine load of 32g. For the DE CTPA virtual monochromatic spectral (VMS) datasets at 40-100keVwere reconstructed. The optimal mean photon energy was determined, and subjective and objective image quality were evaluatedand compared between these datasets. Comparisons between the groups were analyzed with two-way ANOVA or Wilcoxon-Rank-Sum Test depending on the distribution of the data.

RESULTS

For the main pulmonary arteries the 50keV and for the peripheral pulmonary arteries the 40keV dataset provided the highestcontrast-to-noise-ratio (CNR) for both DE CTPA protocols, with significantly higher CNR values for the standard DE CTPA protocol(p<0.05). These 40/50keV VMS datasets resulted in significantly higher CNRs if compared to the standard CTPA protocol for boththe main and peripheral pulmonary arteries, again for both DE CTPA protocols (p<0.05). Subjective image quality did notsignificantly differ for both DE CTPA protocols when compared to the standard CTPA protocol (p>0.05).

CONCLUSION

DE CTPA utilizing image reconstruction at 40/50keV allows for a significant reduction in iodine load while improving vascular signalintensity and maintaining CNR which is especially important in patients with chronic renal insufficiency.


Dual-energy CTPA allows for reducing the contrast media amount by 83%, while maintaining diagnostic image quality. This is ofparticular importance in patients with chronic renal insufficiency

ParticipantsHidenobu Takagi, MD, Sendai, Japan (Presenter) Nothing to DiscloseHideki Ota, MD, PhD, Sendai, Japan (Abstract Co-Author) Nothing to DiscloseKoichiro Sugimura, MD,PhD, Sendai, Japan (Abstract Co-Author) Nothing to DiscloseJunya Tominaga, PhD, Sendai, Japan (Abstract Co-Author) Nothing to DiscloseHiroaki Shimokawa, MD, PhD, Sendai, Japan (Abstract Co-Author) Nothing to DiscloseKei Takase, MD, PhD, Sendai, Japan (Abstract Co-Author) Nothing to Disclose

PURPOSE

To evaluate whether the degree of perfusion defects assessed on lung perfused blood volume (LPBV) images acquired by dual-energy CT allows to estimate the clinical severity of chronic thromboembolic pulmonary hypertension (CTEPH).


SSM05-03 Correlation between Pulmonary Emboli Characteristics and Perfusion Abnormalities in MaterialDecomposition Images of Dual Energy CT (DECT)


This Institutional Review Board-approved retrospective study included 39 consecutive patients with CTEPH (10 men, 29 women).LPBV was imaged with a second-generation dual-source CT scanner. Two radiologists independently scored the degree of perfusiondefects in each lung segment according to the following criteria: score 0, no defect, score 1, defect in less than half of a segment,score 2, defect in more than half of a segment. In case of disagreement, final consensus was reached by mutual discussion. TheLPBV defect score was defined as the sum of the scores of 18 lung segments.Pulmonary artery pressure (PAP), right ventricularpressure (RVP), pulmonary vascular resistance (PVR), cardiac output (CO) and cardiac index (CI) were recorded by right heartcatheterization (RHC). Brain natriuretic peptide (BNP) and 6 minutes walk distance (6MWD) were also recorded.Interobserveragreement was calculated by weighted Cohen's kappa. Correlations between LPBV defect score and RHC-parameters, BNP and6MWD were evaluated by Spearman's rho correlation coefficients. P < 0.05 was considered statistically significant.

RESULTS

Interobserver agreement for scoring perfusion defects on each segment was good (κ = 0.79, 95% confidence interval, 0.75, 0.83).All patients showed abnormal lung perfusion in bilateral lungs with the median LPBV defect score of 16 (range, 5-23). Positivecorrelation of LPBV defect score was found with mean PAP (rho = 0.50, P < 0.01), systolic PAP (rho = 0.55, P < 0.001), diastolicPAP (rho = 0.42, P < 0.01), PVR (rho = 0.57, P < 0.001), RVP (rho = 0.50, P < 0.01) and BNP (rho = 0.42, P < 0.01), a tendency ofnegative correlation with 6MWD (rho = -0.35, P = 0.08). No significant correlation was found with CO (rho = -0.22, P = 0.18) or CI(rho = -0.26, P = 0.11).

CONCLUSION

The LPBV defect score is significantly correlated with RHC- and clinical parameters, and may become a useful tool to estimate theseverity of CTEPH.


LPBV by dual-energy CT is useful for not only detecting abnormal findings of lung perfusion, but also for estimating the clinicalseverity in patients with CTEPH.

ParticipantsAlexi Otrakji, MD, Boston, MA (Presenter) Nothing to DiscloseAmita Sharma, MBBS, Boston, MA (Abstract Co-Author) Nothing to DiscloseEfren J. Flores, MD, Boston, MA (Abstract Co-Author) Nothing to DiscloseJo-Anne O. Shepard, MD, Boston, MA (Abstract Co-Author) Nothing to DiscloseMannudeep K. Kalra, MD, Boston, MA (Abstract Co-Author) Nothing to DiscloseSubba R. Digumarthy, MD, Boston, MA (Abstract Co-Author) Nothing to DiscloseShaunagh McDermott, FFR(RCSI), Boston, MA (Abstract Co-Author) Nothing to DiscloseAzadeh Tabari, Boston, MA (Abstract Co-Author) Nothing to Disclose

PURPOSE

To assess relationship between iodine distribution abnormalities in pulmonary blood volume (PBV) images and type of pulmonaryemboli (occlusive versus non-occlusive) in virtual monochromatic DECT images.


Our study included 57 patients (mean age 59±15years, M:F 25:32, mean weight 77±19kg) who had pulmonary embolism on chestDECT. All CT exams were performed on single or dual source MDCT scanners capable of DECT. Virtual monochromatic (40-60keV),and PBV images were used for assessment. Images evaluated for enhancement in pulmonary arteries, the location of filling defectsand their characteristics (occlusive vs non-occlusive). Pulmonary abnormalities were evaluated synchronously on virtualmonochromatic and PBV images for location, shape, size, enhancement, and likely diagnosis. The presence of right heart strain(RHS) and diameter of pulmonary trunk were recorded. The CTDI vol, DLP were recorded. Data were analyzed using ANOVA andstudent's t-test.

RESULTS

Mean CTDI vol was 8±2 mGy (range:5-16). Mean pulmonary trunk diameter was 26±5 mm (15-44). Optimal/excellent enhancementin subsegmental pulmonary arteries was seen in 89% of cases. RHS was predicted in 40% of cases (23/57). Occlusive PEs (OPEs,present in 47/57 patients) was seen most commonly at segmental level (53%). Discordant pulmonary infarctions (characterized byPBV defects larger than size of radiographic opacity on lung window) were seen in 30% of cases, and were most often associatedwith segmental OPEs (28% of OPEs cases). Mismatched defects (defects seen on PBV without abnormality on lung window) wereseen in 14% of cases, and were always associated with segmental OPEs (17% of total OPEs). Size-concordant infarctions anddefects (size of PBV abnormality equal to radiographic abnormalities) were seen in 21% and 15% of OPEs cases, respectively. Intotal, 66% of total OPEs were associated with infarction or defects. Infarcts or PBV defects were noticed in 70% of expected RHScases.

CONCLUSION

Presence of pulmonary infarction or perfusion defect on pulmonary blood volume images is a good predictor for presence ofocclusive lobar or segmental pulmonary embolism as well as right heart strain.


Presence of occlusive pulmonary emboli requires interpretation of PBV images to rule out any perfusion defects.

Honored Educators

Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifyingeducational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-qualityeducational content in their field of study. Learn how you can become an honored educator by visiting the website at:

SSM05-04 Do We Really Need Bolus Tracking for Chest CT Angiography?: Assessment of Fixed Delay ProlongedBlous (FDPB) Contrast Injection Protocol, for Optimal Vascular Enhancement


SSM05-05 Observer Performance at Varying Dose Levels and Reconstruction Methods for Detection ofIndeterminate Pulmonary Nodules


https://www.rsna.org/Honored-Educator-Award/


ParticipantsAlexi Otrakji, MD, Boston, MA (Presenter) Nothing to DiscloseShaunagh McDermott, FFR(RCSI), Boston, MA (Abstract Co-Author) Nothing to DiscloseEfren J. Flores, MD, Boston, MA (Abstract Co-Author) Nothing to DiscloseJo-Anne O. Shepard, MD, Boston, MA (Abstract Co-Author) Nothing to DiscloseMannudeep K. Kalra, MD, Boston, MA (Abstract Co-Author) Nothing to DiscloseSubba R. Digumarthy, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose

PURPOSE

To assess the feasibility of fixed delay prolonged bolus(FDPB) contrast injection during routine chest CT for evaluation ofmediastinal and pulmonary vessels as compared to CT pulmonary angiography(CTPA) done with triggered bolus tracking(BT)techniques.


Of the 100 patients included in our study, 50 patients underwent routine chest CT with FDPB(M:F 29:21, mean age 59±18 years,mean weight 77±15kg) and 50 weight-matched patients had CTPA using BT(4 cc/second, 370 mg%, 80ml), M:F 23:27, mean age57±17 years, mean weight 77±15 kg. Patients weighing more than 90 kg and who got contrast injection via central venous catheterwere excluded. The FDP injection involved administration of 25ml of contrast (370 mg%) at rate of 1ml/second followed by 55mlcontrast at rate of 2.2ml/second with scanning at 57 second fixed delay. All CT scans were performed on (128-slice SiemensDefinition Edge MDCT) using automatic kV selection technique(Care kV). All exams were assessed subjectively for vascularabnormalities (in pulmonary arteries, aorta, and heart), and artifacts. HU values in main pulmonary arteries and aorta, CTDI vol andDLP were recorded. Data were analyzed using student's t-test.

RESULTS

Mean CTDI vol was 5±1.3 mGy for FDPB. Mean HU for FDPB in main pulmonary artery and ascending aorta were 311±79 and 305±49, respectively, with corresponding values of 371±110 and 219±88 for CTPA-BT. Optimal/excellent contrast enhancement atsegmental level was seen in 92% of cases for FDPB compared to 86% for CTPA-BT examinations(p=0.9). The inability to rule outcentral pulmonary emboli was noticed in 3% of cases for FDPB and CTPA-BT. FDPB resulted in significantly superior enhancement inheart and thoracic aorta in all patients compared to CTPA-BT. Contrast streak artifacts were also substantially lower on FDPB thanon CTPA-BT(p<0.001). For FDPB, 5% of cases revealed incidental pulmonary emboli compared to 9% of cases for CTPA-BT atsegmental level.

CONCLUSION

Fixed delay prolonged contrast injection protocol can provide optimal contrast enhancement in pulmonary arteries, heart, and aortacompared to the bolus tracking technique. The prolonged injection results in substantially less artifacts.


Fixed delay prolonged bolus of chest CT has the potential to be as the only chest contrast enhanced CT protocol for the evaluationof vascular and non-vascular chest abnormalities.

Honored Educators



ParticipantsJoel G. Fletcher, MD, Rochester, MN (Presenter) Grant, Siemens AG; ; David L. Levin, MD, PhD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseAnne-Marie G. Sykes, MD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseRebecca M. Lindell, MD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseDarin B. White, MD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseRonald S. Kuzo, MD, Jacksonville, FL (Abstract Co-Author) Nothing to DiscloseLifeng Yu, PhD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseMaria Shiung, Rochester, MN (Abstract Co-Author) Nothing to DiscloseAdam Bartley, Rochester, MN (Abstract Co-Author) Nothing to DiscloseShuai Leng, PhD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseDavid R. Holmes Iii, PhD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseAlicia Toledano, DSc, Washington, DC (Abstract Co-Author) President, Biostatistics Consulting, LLCRickey Carter, PhD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseCynthia H. McCollough, PhD, Rochester, MN (Abstract Co-Author) Research Grant, Siemens AG

PURPOSE

SSM05-06 The Usefulness of a Dictionary Learning Post-processing Technique for Improving Image Quality ofLow-Dose Chest CT


To estimate the ability to detect indeterminate pulmonary nodules ≥ 5 mm (IPNs) at varying dose levels using standard filtered backprojection (FBP) and iterative reconstruction (sinogram-affirmed iterative reconstruction; SAFIRE) using a two-stage study design.


In stage 1, CT projection data from 44 chest CT exams performed using automatic exposure control [70 Quality ref. mAs (QRM)]were collected. IPNs were identified by two thoracic radiologists who did not participate in the reader study. Using a validated noiseinsertion tool to simulate reduced doses, 10 datasets were reconstructed for each patient (FBP and SAFIRE at 5 dose levels each(2.5, 5, 10, 30, and 70 QRM); 440 total cases). In each reading session, 3 thoracic radiologists randomly evaluated each patient'sdata once using thin 1 mm axial and MIP images. Using a dedicated computer workstation, readers tightly circumscribed all IPNs,gave a confidence score (0 - 100), and graded image quality. A successful interpretation was defined as ≥ 2 readers localizing all"essential" IPNs (or no non-lesion localizations in negative cases), where an essential IPN was identified by the reference standardand ≥ 2 readers at 70 QRM FBP. Sample size calculations (p0=0.8, p1=0.9, alpha=0.05 (one sided)) determined ≥ 37 cases to passthrough stage I. JAFROC analysis was also performed on a per-lesion basis using a non-inferiority limit of -0.1.

RESULTS

Dose levels of ≥ 5 QRM (or 2.5 QRM using SAFIRE) met stage 1 criteria for correct interpretation. Using non-inferiority criteria, theJAFROC figure of merit was also non-inferior for all configurations except for 2.5 QRM FBP. At 5 QRM, pooled sensitivities andspecificities were nearly identical between FBP and SAFIRE (FBP: 87% [95% CI: 70-95%] and 88% [74-95%], SAFIRE: 86% [69-94%] and 91% [75-97%]; respectively). Diagnostic image quality was greater for SAFIRE images at 10 - 70 QRM (p<0.05).

CONCLUSION

CT images reconstructed at dose levels corresponding to 5 - 30 QRM (and at 2.5 QRM when using SAFIRE) performed similar to 70QRM FBP in this pilot study for detection of IPNs. Further study is needed to confirm this large potential for dose reduction.


Whether or not iterative reconstruction is used, the radiation dose for screening or surveillance chest CT can be substantiallylowered without compromising observer performance.

ParticipantsYoshinori Kanii, MD, Tsu, Japan (Presenter) Nothing to DiscloseYasutaka Ichikawa, MD, Matsusaka, Japan (Abstract Co-Author) Nothing to DiscloseRyohei Nakayama, PhD, Kusatsu, Japan (Abstract Co-Author) Nothing to DiscloseMotonori Nagata, MD, PhD, Tsu, Japan (Abstract Co-Author) Nothing to DiscloseMasaki Ishida, MD,PhD, Tsu, Japan (Abstract Co-Author) Nothing to DiscloseKakuya Kitagawa, MD, PhD, Tsu, Japan (Abstract Co-Author) Nothing to DiscloseShuichi Murashima, MD, Tsu, Japan (Abstract Co-Author) Nothing to DiscloseHajime Sakuma, MD, Tsu, Japan (Abstract Co-Author) Departmental Research Grant, Siemens AG; Departmental Research Grant,Koninklijke Philips NV; Departmental Research Grant, Bayer AG; Departmental Research Grant, Guerbet SA; Departmental ResearchGrant, DAIICHI SANKYO Group; Departmental Research Grant, FUJIFILM Holdings Corporation; Departmental Research Grant, NihonMedi-Physics Co, Ltd

PURPOSE

Low-dose CT is widely used for lung cancer screening. In low-dose conditions, however, CT images are prone to have increasednoise and low-contrast detectability. Recently, our group developed a super-resolution (SR) technique based on a dictionary forenhancing image quality in MR angiography. The purpose of this study was to improve the image quality of low-dose CT byexpanding the concept of the SR technique.


Chest CT was acquired with 64-slice CT (Discovery CT750HD) by using a standard current of 200-300mA and a reduced current of20mA in 12 patients who were referred for chest CT. We developed an image improvement method that consists of (1) generationof a dictionary representing the relationship between standard- and low-dose patches adopted from standard- and low-dose CTdatasets, and (2) construction of high quality image from low-dose CT dataset by embedding optimal patches selected from thedictionary. For each patient, standard- and low-dose CT datasets in the remaining 11 patients were used to generate thedictionary. This procedure was repeated for all 12 patients. Image noise was evaluated as the standard deviation of CT intensity inthe descending aorta. Qualitative assessment of image quality was performed for the mediastinum and lung by using a 5-point scale(5=excellent, 1=very poor) by two observers. In addition, image quality of abnormal lung structures (nodules or consolidation) werealso assessed on a 5-point scale as well.

RESULTS

Image noise on low-dose CT was significantly reduced by using the dictionary learning method (20.4±7.9 HU vs 48.5±13.7 HU,p=0.0005). For image quality of the lung and mediastinum, low-dose CT generated by the dictionary learning method was ratedsignificantly better than original low-dose CT (lung, score 2.8±0.6 vs 1.9±0.7, p=0.0039; mediastinum, score 2.9±0.8 vs 2.3±0.8,p=0.0078). Image quality of abnormal lung structures was also significantly improved by using the new technique (score 3.4±0.6 vs2.7±0.6, p=0.0273).

CONCLUSION

The dictionary learning post-processing method can provide significantly improved image quality and reduced image noise on low-dose chest CT.


Substantial improvement of image quality can be achieved by using the dictionary learning-based method on low-dose chest CT,leading to more accurate interpretation, while minimizing radiation dose.

SSM11-01 Genitourinary Keynote Speaker: Safety and Efficacy of Corticosteroid Prophylaxis

Wednesday, Dec. 2 3:00PM - 3:10PM Location: E352

SSM11-02 The Effect of IV Contrast on Renal Function in Patients on Metformin


SSM11-03 The Presence of a Solitary Kidney is not an Independent Risk Factor for Acute Kidney InjuryFollowing Contrast-enhanced CT


SSM11

ISP: Genitourinary (Intravenous Contrast Issues and CT Dose Reduction)


CT GU SQ


ParticipantsMatthew S. Davenport, MD, Cincinnati, OH (Moderator) Book contract, Wolters Kluwer nv; Book contract, Reed Elsevier; Dean A. Nakamoto, MD, Beachwood, OH (Moderator) Research Grant, Galil Medical Ltd; Research agreement, Toshiba Corporation

Sub-Events

ParticipantsMatthew S. Davenport, MD, Cincinnati, OH (Presenter) Book contract, Wolters Kluwer nv; Book contract, Reed Elsevier;

ParticipantsCody W. McHargue, BA, San Francisco, CA (Presenter) Nothing to DiscloseArti D. Shah, MD, San Francisco, CA (Abstract Co-Author) Nothing to DiscloseJudy Yee, MD, Clayton, CA (Abstract Co-Author) Research Grant, EchoPixel, IncPriyanka Jha, MBBS, Sacramento, CA (Abstract Co-Author) Nothing to DiscloseIsabel Allen, San Francisco, CA (Abstract Co-Author) Nothing to DiscloseDonald Chau, BA, San Francisco, CA (Abstract Co-Author) Nothing to DiscloseRobert Rushakoff, MD, San Francisco, CA (Abstract Co-Author) Nothing to Disclose

PURPOSE

Due to concerns of acute kidney injury and the theoretical risk of lactic acidosis with metformin, the Food and Drug Administrationmandates that metformin be held for two days after intravenous (IV) contrast until renal function is checked and in an acceptablerange. However, there is minimal evidence to support this practice. Further investigation is warranted.


We conducted a retrospective cohort study of 130 adult outpatients at the San Francisco Veterans Affairs Medical Center todetermine if there was a change in renal function in diabetic patients on metformin who underwent computed tomography (CT)scans with IV contrast between 2007-2014. Patients were excluded if immediately hospitalized after the CT scan. The generalizedestimating equations method was used to determine whether IV contrast and pre-contrast creatinine (Cr; or pre-contrastestimated glomerular filtration rate [eGFR]) were associated with a change in Cr (or eGFR). Covariates included: age, gender, BMI,diabetes (DM) duration and HbA1c.

RESULTS

In our cohort, mean age was 67±10 years, 119 (91%) were male, 71 (55%) were Caucasian, and 63 (49%) were higher risk (pre-contrast eGFR <60 ml/min/1.73m2). Mean DM duration was 6.5±6.0 years and mean HbA1c was 7.1±1.3%. Mean pre- and post-contrast Cr were 1.13±0.25 mg/dL and 1.09±0.26 mg/dL; p=0.02 (overall t-test). Mean pre- and post-contrast eGFR were 72±24ml/min/1.73m2 and 75±26 ml/min/1.73m2; p=0.006 (overall t-test). In fully-adjusted models, there was a significant decrease in Crpost-contrast: β-coefficient -0.24 (95% confidence interval [CI] -0.35 to -0.12), p<0.001. There was no significant change ineGFR post-contrast: β-coefficient -0.06 (95% CI -0.16 to 0.03), p=0.19. A subgroup analysis of patients with pre-contrast eGFR <60 ml/min/1.73m2 showed similar results.

CONCLUSION

There is no evidence of deterioration in renal function in outpatients on metformin who receive IV contrast, even in a cohort with alarge proportion of higher risk patients. Therefore, our results suggest that the current practice of holding metformin after IVcontrast should be re-evaluated.


The practice of holding metformin and checking Cr two days after IV contrast should be re-evaluated as there was no evidence tosuggest a decline in renal function in a cohort with high risk patients.

ParticipantsJennifer S. McDonald, PhD, Rochester, MN (Abstract Co-Author) Research Grant, General Electric CompanyRichard W. Katzberg, MD, Sacramento, CA (Abstract Co-Author) Research Grant, Siemens AG Research Grant, Bayer AGInvestigator, Siemens AG Investigator, Bayer AGRobert J. McDonald, MD, PhD, Rochester, MN (Presenter) Nothing to DiscloseEric E. Williamson, MD, Rochester, MN (Abstract Co-Author) Research Grant, General Electric CompanyDavid F. Kallmes, MD, Rochester, MN (Abstract Co-Author) Research support, Terumo Corporation Research support, Medtronic, Inc

SSM11-04 New Insights in the MRI Excretory Phase: The Use of Gd-EOB-DTPA for the Evaluation of theExcretory System


SSM11-05 Feasibility and Image Quality of Reduced Dose CT Intravenous Pyelogram Using Model-BasedIterative Reconstruction in Patients with Hematuria


Research support, Sequent Medical, Inc Research support, Benvenue Medical, Inc Consultant, General Electric Company Consultant,Medtronic, Inc Consultant, Johnson & Johnson

PURPOSE

To determine whether patients with a solitary kidney are at higher risk for contrast-induced acute kidney injury (AKI) than matchedcontrol bilateral kidney patients.


This retrospective study was HIPAA compliant and approved by our Institutional Review Board. Adult patients with bilateral kidneysor a solitary kidney from unilateral nephrectomy who received a contrast-enhanced computerized tomography (CT) scan at ourinstitution from January 2004 to August 2013 were identified. The effects of contrast exposure on the rate of AKI (defined as a risein maximal observed serum creatinine (SCr) of either 1) > 0.5 mg/dL or 2) > 0.3 mg/dL or 50% over baseline within 24-72 hours ofexposure), and 30-day post-scan emergent dialysis and death were determined following propensity score-based 1:3 matching ofsolitary and control bilateral kidney patients.

RESULTS

Propensity score matching yielded a cohort of 247 solitary kidney patients and 691 bilateral kidney patients. The rate of AKI wassimilar between the solitary and bilateral kidney groups [SCr > 0.5 mg/dL AKI definition odds ratio (OR) = 1.11 (95% confidenceinterval (CI) 0.65 - 1.86); p = 0.70; SCr > 0.3 mg/dL or 50% AKI definition OR = 0.96 (95% CI 0.41 - 2.07). p = 0.99]. The rate ofemergent dialysis was rare and also similar between cohorts (OR = 1.87 (0.16-16.4), p=.61). Though the rate of mortality washigher in the solitary kidney group (OR = 1.70 (1.06-2.71), p=.0202), chart review found that no death was attributable to AKI.

CONCLUSION

This study did not detect any significant differences in the rate of AKI, dialysis, or death attributable to contrast-enhanced CT inpatients with solitary versus bilateral kidneys.


Contrast-enhanced CT protocols can be guided by image optimization, rather than contrast-induced nephropathy risk in solitarykidney patients.

ParticipantsCaterina Colantoni, MD, Milan, Italy (Presenter) Nothing to DiscloseAntonio Esposito, MD, Milan, Italy (Abstract Co-Author) Nothing to DiscloseAnna Palmisano, MD, Milan, Italy (Abstract Co-Author) Nothing to DiscloseFrancesco A. De Cobelli, MD, Milan, Italy (Abstract Co-Author) Nothing to DiscloseAlessandro Del Maschio, MD, Milan, Italy (Abstract Co-Author) Nothing to Disclose

PURPOSE

Excretory MR urography is a useful complementary technique in many MR imaging studies of the abdomen to assess kidneyexcretion and the urinary collecting system. However, after the injection of a standard dose gadolinium-based contrast media,frequently, the collecting system is unassessable for T2* effect due to very high concentration of Gd in the urine. Aim of thepresent study was to compare the enhancement of the urinary collecting system after the injection of a single standard dose ofGd-based contrast media known for different renal excretion rates: Gadobutrol, Gadobenate dimeglumine, and Gd-EOB-DTPA.


In 60 patients (pts) with normal creatinine clearance and without urinary tract dilatation, mean signal intensities (pixel values) ofthe renal pelvis and of the paravertebral muscles for the calculation of renal pelvis/skeletal muscle ratio, were evaluated on 3D fastT1-weighted gradient-echo sequences with fat suppression obtained during excretory phase after intravenous injection of 0.1mmol/kg contrast media: 20pts were studied with Gadobutrol, 20pts with Gadobenate dimeglumine, and 20pts with Gd-EOB-DTPA,respectively. Urinary collecting system was considered assessable/not-assessable according to the presence of T2* effect.

RESULTS

The mean signal intensities of renal pelvis were 1954±1368.5 (pixel values) for Gadobutrol, 2488±843.8 for Gadobenate dimeglumine,and 3605±1025.3 for Gd-EOB-DTPA, respectively. The mean signal intensity ratio was 2.2±1.59 for Gadobutrol, 2.7±0.88 forGadobenate dimeglumine, and 3.8±1.46 for Gd-EOB-DTPA. No significant differences were found between the mean signal intensityratio of Gadobutrol and that of Gadobenate dimeglumine (p>0.05); significant differences were found between the mean signalintensity ratio of Gadobutrol and of Gd-EOB-DTPA (p<0.005), and that of Gadobenate dimeglumine and of Gd-EOB-DTPA (p<0.001).Urinary collecting system was considered not-assessable in 8/20pts for Gadobutrol, in 1/20pt for Gadobenate dimeglumine, and in0/20pts for Gd-EOB-DTPA.

CONCLUSION

The urinary collecting system was considered assessable in all pts studied after injection of a standard dose of Gd-EOB-DTPA, andthis could be due to the low urine excretion rate.


The use of Gd-EOB-DTPA in the excretory MR urography can improve the assessability of the excretory system, with no evidence ofT2* shortening effects.

SSM11-06 Reduced Radiation Dose with Iterative Reconstruction in 100 kVp CT Urography: With differentIodine Dosage


ParticipantsIsabelle Boulay-Coletta, MD, Paris, France (Abstract Co-Author) Nothing to DiscloseLinda N. Morimoto, MD, Stanford, CA (Presenter) Nothing to DiscloseDominik Fleischmann, MD, Palo Alto, CA (Abstract Co-Author) Research support, Siemens AG; Lior Molvin, Stanford, CA (Abstract Co-Author) Speakers Bureau, General Electric CompanyLu Tian, Stanford, CA (Abstract Co-Author) Nothing to DiscloseJuergen K. Willmann, MD, Stanford, CA (Abstract Co-Author) Research Consultant, Bracco Group; Research Consultant, Triple RingTechnologies, Inc; Research Grant, Siemens AG; Research Grant, Bracco Group; Research Grant, Koninklijke Philips NV; ResearchGrant, General Electric Company

PURPOSE

To evaluate the feasibility and image quality of Reduced Dose (RD) CT Intravenous Pyelogram (IVP) using Model-Based IterativeReconstruction (MBIR) compared to Standard Dose (SD) CT IVP using Adaptive Statistical Iterative Reconstruction (ASIR) inpatients referred for work-up of hematuria.


In this IRB approved and HIPAA compliant study, 66 consecutive patients (44 males and 22 women; mean age, 62 years; mean BMI,27 kg/m²) referred for a dual phase CT IVP (non-contrast and combined split-bolus nephrographic-excretory phase) wereprospectively included and either imaged with SD CT IVP with 40% ASIR technique (n=34) or RD CT IVP with MBIR technique (n=32)on a 64-slice CT scanner (GE Discovery 750 HD). Quantitative measurements of image noise on both non-contrast and post-contrast imaging in addition to radiation dose and patients' BMI were recorded by one reader. Two independent, blinded readersassessed subjective image quality, including image noise, sharpness of the renal cortex and collecting system (calyces, renal pelvis,ureters, and bladder), presence of artifacts, and overall image quality impression on non-contrast and post-contrast images utilizing4 or 5-point grading scales.

RESULTS

Both patient groups were not significantly different (26.8 +/- 7.8 kg/m² versus 27.5 +/- 4.8 kg/m²) in regards to BMI. Radiationdose was reduced by an average of 49% (p<0.01) on RD CT IVP (CTDI vol = 7.7 +/- 2.8 mGy) compared to SD CT IVP (CTDI vol=15.1 +/- 4.8 mGy) on post-contrast imaging. Overall dose reduction averaged 36% with non-contrast and contrast-enhancedimaging (RD CT IVP CTDIvol =15.31 +/- 2.8 mGy versus SD CT IVP CTDI vol = 23.91 +/- 5.3 mGy). Overall image quality impressionof the collecting system, artifacts, and image sharpness were not significantly different (p>0.05) between RD CT IVP and SD CTIVP. Subjective image noise was significantly lower (p<0.01) in RD CT IVP, which was also reflected by a quantitative reduction ofimage noise by an average of 44% (p<0.01) on non-contrast imaging and 37% (p<0.01) on post-contrast imaging.

CONCLUSION

RD CT IVP is feasible and allows for a substantial dose reduction compared to SD CT IVP protocol without compromising imagequality.


Introduction of iterative reconstruction algorithms which can be implemented with routine clinical CT IVP protocols to reduceradiation exposure while yielding diagnostic quality images.

ParticipantsHuihui Wang, MD, Beijing, China (Presenter) Nothing to DiscloseJuan Hu, Kunming, China (Abstract Co-Author) Nothing to DiscloseXuedong Yang, Beijing, China (Abstract Co-Author) Nothing to DiscloseXiaoying Wang, MD, Beijing, China (Abstract Co-Author) Nothing to DiscloseHe Wang, MD, Beijing, China (Abstract Co-Author) Research Grant, General Electric CompanyJian Jiang, MD, Beijing, China (Abstract Co-Author) Research Grant, General Electric Company

PURPOSE

To evaluate the image quality and radiation dose in CT urography at 100kVp with iterative reconstruction, combining a differentiodine dosage.


This study was approved by the institutional review board. From March to June 2012, 45 consecutive patients who underwent CTUfor hematuria were divided into 3 groups: group A, 100kVp and 0.9mL/kg contrast material (CM) (9 men, 6 female; mean age 49.4years; mean BMI 22.6kg/m2); group B, 100kVp and 1.1mL/kg CM (8 men,7 female; mean age 50.1years; mean BMI 22.6kg/m2);group C, 120kVp and 1.1mL/kg CM (13men, 2 female; mean age 58.5 years, mean BMI 23.5kg/m2). Automatic tube current wasused in all groups. The 100kVp images (group A and B) were reconstructed with 80% adaptive statistical iterative reconstruction(ASiR), while filter back projection (FBP) for 120kVp images (group C). Urinary tract was divided into 11 segments, and mean CTvalues and contrast-to-noise ratio (CNR) of each segment in the excretory phase were measured respectively in 3 groups. Theradiation dose in excretory phase was compared (volume computed tomography dose index, CTDIvol; size-specific dose estimate,SSDE and estimated effective dose, ED).

RESULTS

There were no significant differences among group A, B and C for age, BMI and transverse circumstance (all P>0.05). Allexaminations were considered to be of acceptable image quality and inter-observer agreement was good (K=0.717, P<0.001). Therewere no significant differences in mean attenuations of all urinary segments among 3 groups (P>0.05). Image noise was much lessin group A and B (both P<0.001) than that of group C, but there was no significant difference between group A and B (P=0.934).CNRs in most segments were higher in group B than group C(P=0.001~0.062) and similar between group A and C(P=0.024~0.896),but there were no notable differences in CNRs between group A and B (P>0.05). Mean CTDIvol, SSDE and ED in excretory phase in

group A and B were significantly lower than those of group C(P<0.05). Iodine dosage was reduced by 18.2% in group A than groupB and C.

CONCLUSION

Given subjective and objective image quality, CTU at 100 kVp with 80% ASiR resulted in reduction of radiation dose, and 0.9mL/kgCM (320mgI/ml) iodine dosage was workable.


High radiation exposure and Contrast-Induced Nephropathy for CTU have drawn much attention and anxiety, 100kVp with 80% ASiRand 0.9mL/kg CM may offer a means of resolution.

SSM12-01 Health Service, Policy and Research Keynote Speaker: Medical/Practice Management

Wednesday, Dec. 2 3:00PM - 3:10PM Location: S102D

SSM12-02 Using Modality Log Files to Guide MR Protocol Optimization and Improve Departmental Efficiency


SSM12-03 Comparison between Tumor Evaluation Using Free-text and RECIST 1.1 Criteria in Everyday Work


SSM12

ISP: Health Service, Policy and Research (Medical/Practice Management)


MR HP SQ


ParticipantsJames V. Rawson, MD, Augusta, GA (Moderator) Nothing to DisclosePaul P. Cronin, MD, MS, Ann Arbor, MI (Moderator) Nothing to Disclose

Sub-Events

ParticipantsJames V. Rawson, MD, Augusta, GA (Presenter) Nothing to Disclose

ParticipantsMartin L. Gunn, MBChB, Seattle, WA (Presenter) Research support, Koninklijke Philips NV; Spouse, Consultant, Wolters Kluwer NV;Medical Advisor, TransformativeMed, Inc; Bruce E. Lehnert, MD, Seattle, WA (Abstract Co-Author) Research support, Koninklijke Philips NVJeffrey H. Maki, MD, PhD, Seattle, WA (Abstract Co-Author) Research support, Bracco Group; Speakers Bureau, Lantheus MedicalImaging, Inc; Christopher Hall, PhD, Briarcliff Manor, NY (Abstract Co-Author) Employee, Koninklijke Philips NVThomas Amthor, Hamburg, Germany (Abstract Co-Author) Employee, Koninklijke Philips NVJulien Senegas, Hamburg, Germany (Abstract Co-Author) Employee, Koninklijke Philips NVNorman J. Beauchamp JR, MD, Seattle, WA (Abstract Co-Author) Research Grant, Koninklijke Philips NV

PURPOSE

Imaging equipment log files contain detailed data about workflow and equipment utilization that is unavailable on RIS and PACSsources. The purpose of this study was to investigate the use of log files to identify areas of waste based on scanner time,variability and number of sequances, and measure the impact of a departmental MR efficiency process.


Log files (MRLFs) were extracted from 4 MR scanners from 07/2013 to 02/2015 and were parsed to extract several parameters (e.g.protocol, sequences, exam duration, idle time, table movement). Using RIS data and MRLFs, we identified protocols with thegreatest volume, duration and variation. Using MRLFs, we monitored system utilization of liver mass (MRLiv) and abdo/pelvis survey(MRAP) protocols pre and post protocol optimization. Optimization included assigning MRLiv patients with cirrhosis undergoing HCCscreening to a new abbreviated protocol (MRLivCirr), and sequence reduction and optimization (MRAP). Statistical comparisonsincluded a 2 tailed T-test and F-test.

RESULTS

Mean monthly MRLiv patient volume (+/- s.d.) was 55 ± 16 before and 20 ± 1 after optimization. The remaining 38 +/- 18patients/month were for HCC screening and were assigned to the new MRLivCirr protocol. Mean monthly MRAP exams before was20.6 ± 7.3 and after was 17.6 ± 2.3. Exam duration (table time ± s.d.) for MRLiv patients was 30.9 ± 9.3 min before and 31.4 ±11.7 min after (p=0.7). However, for patients in the new MRLivCirr protocol group, mean time reduced by 7.2 min/exam to 23.7 ±7.9 min(p<0.001). Duration for patients undergoing MRAP reduced from 52.9 ±16.6 min to 43.1± 15.6 min, saving 9.8 min/exam(p<0.001). At an estimated rate of $650/hr, potential yearly savings could reach $36k for cirrhosis screening, and $22k for MRAPpatients. The predictability of the exam length was improved with the s.d. of the MRLivCirr group (7.9 min) lower than the MRLivgroup (11.7 min); F-Test, p<0.02.

CONCLUSION

MRLFs can be used to identify opportunities for equipment utilization improvement and measure the impact with accuracy. Duringour process we were able measure exact time savings and decreased variability per patient.


Log files provide a way to measure modality utilization during image acquisition that are unavailable from RIS and PACS sources.They can be used to evaluate operational improvements in the department, potentially saving cost, and improving patientsatisfaction.

ParticipantsJuliane Schelhorn, MD, Essen, Germany (Abstract Co-Author) Nothing to DiscloseJulia Hoischen, Duesseldorf, Germany (Abstract Co-Author) Nothing to DiscloseHaemi P. Schemuth, Essen, Germany (Presenter) Nothing to DiscloseElena Stenzel, Essen, Germany (Abstract Co-Author) Nothing to Disclose

SSM12-04 Implementing a Collaborative Approach to Imaging Utilization Managementat a Provider-OwnedManaged Services Organization


Felix Nensa, MD, Essen, Germany (Abstract Co-Author) Nothing to DiscloseKai Nassenstein, Essen, Germany (Abstract Co-Author) Nothing to Disclose

PURPOSE

Different criteria have been established to improve and standardize tumor response evaluation. Currently, these criteria are used inclinical trials, but are rarely employed in daily work. This retrospective study compared tumor response evaluation by free-text andRECIST 1.1 criteria in everyday tumor patients.

RESULTS

Main included tumor entities were lung (17%), colorectal (16%), and breast cancer (14%). Median time intervals between CTfollow-ups were 9-12 weeks. At first follow-up, 51% of patients were rated with different response categories comparing free-textand RECIST 1.1. This was significant (p<0.001) with an obvious underrepresentation of SD and an overrepresentation of PR and PDin free-text evaluation. At second follow-up, 46% had categorical differences, which was significant (p<0.003). At the later follow-ups, categorical differences were obvious, but not significant (3. follow-up: 42% differences, p=0.570; 4. follow-up: 35%, p=0.824;5. follow-up: 47%, p=0.209). The severity of categorical differences increased with increasing follow-up time (up to a difference ofthree response categories) due to different reference points used for image analysis.

CONCLUSION

Severe differences in tumor response evaluation were detected comparing evaluation by free-text and RECIST 1.1. Given this,tumor response criteria should be implemented in the daily routine.


To improve routine tumor patient monitoring tumor response criteria should be used in everyday work.

ParticipantsDaniel Durand, MD, Baltimore, MD (Presenter) Stockholder, Evolent Health, LLC; Advisor, National Decision Support Company;Advisor, Radiology Response; Founder, am-I-ok.comCriag Reich, MD, Oakland, CA (Abstract Co-Author) Nothing to DiscloseJeffrey D. Robinson, MD, MBA, Seattle, WA (Abstract Co-Author) Consultant, HealthHelp, LLC; President, Clear Review, Inc; David B. Larson, MD, MBA, Los Altos, CA (Abstract Co-Author) Intellectual property license agreement, Bayer AG; Potentialroyalties, Bayer AGRichard Sankary, MD, Oakland, CA (Abstract Co-Author) Nothing to Disclose

PURPOSE

While effective at controlling utilization, radiology benefit managers (RBMs) are disliked because they require ordering physicians todemonstrate medical necessity to an imaging gatekeeper who is not part of the community in which care occurs. Provider-ownedhealth plans often utilize RBMs because their non-radiologist Medical Directors (MDs) are not imaging specialists. The purpose of ourstudy was to demonstrate that radiologists can train local MDs to be effective stewards of imaging using collaborative techniquesand produce results on par with RBMs but with fewer denials.


A provider-owned Managed Services Organization (MSO) underwent an imaging utilization management (UM) process redesign. Priorto 2015, only PET/CTs and MRI exams ordered by primary care physicians were reviewed. After 1/1/15, all requests for CT, MRI,PET/CT, nuclear caradiology, and echocardiography were reviewed using Milliman Care Guidelines. The UM MD staff attended a day-long workshop led by two radiologists expert in collaborative imaging stewardship. The peer-to-peer process was rescripted toemphasize the risks of imaging (e.g. radiation) and suggesting alternative management plans (e.g. alternative imaging modalities)when appropriate. To assess the efficacy of the intervention, the MSO pre-authorization database was queried for the interventionperiod (Q1 2015) and a seasonally-matched baseline period (Q1 2014). The data elements extracted are shown in Figure 1. Impactrate was defined as the percentage of cases modified, withdrawn, or denied.

RESULTS

There was a significant increase in impact rate (0.4% vs. 4.6%, p=0.005) during the intervention period versus the control period.The number of requests modified or withdrawn by the ordering physician increased significantly (0.4% vs. 3.8%, p=0.01), while thenumber of requests denied by MDs was not significantly different (0.0% vs. 0.6%, p=0.51). Overall, the number of studiesauthorized per 1,000 patients declined significantly after the intervention (96.8 vs. 89.0, p=0.006).

CONCLUSION

Local MDs trained by radiologists can be effective stewards of imaging by using collaborative techniques that significantly reduceunnecessary imaging utilization without significantly increasing the use of denials.


Radiologists can create significant value for health systems by training local MDs to be effective stewards of imaging UM usingcollaborative techniques.

Honored Educators



SSM12-05 Has Use of Prostate Biopsy and Transrectal Ultrasound Declined as Concerns Mount aboutOverdiagnosis of Prostate Cancer?


SSM12-06 Calmative Training of MR Imaging Support Staff Improving Study Completion Rates and PatientShow-Up Rates


ParticipantsDavid C. Levin, MD, Philadelphia, PA (Presenter) Consultant, HealthHelp, LLC; Board of Directors, Outpatient Imaging Affiliates, LLCLaurence Parker, PhD, Philadelphia, PA (Abstract Co-Author) Nothing to DiscloseEthan J. Halpern, MD, Philadelphia, PA (Abstract Co-Author) Nothing to DiscloseVijay M. Rao, MD, Philadelphia, PA (Abstract Co-Author) Nothing to Disclose

PURPOSE

In recent years there has been considerable debate about the issue of overdiagnosing prostate cancer (PCa). Since it is often anindolent disease and the potential harms from diagnosis and treatment are considerable, some have advocated a more conservativeapproach to conducting screening and diagnostic procedures. For example, the U.S. Preventive Services Task Force has issued agrade D recommendation against PSA-based screening. Our purpose was to study trends in the use of prostate biopsy (PB) andtransrectal ultrasound (TRUS) over a recent 13-year period.


The nationwide Medicare Part B Physician/Supplier Procedure Summary Master Files for 2001 through 2013 were used. They coverall Medicare fee-for-service beneficiaries (17.2 million males in 2013). CPT codes for PB and TRUS were selected and trends inprocedure volume were evaluated. Utilization rates per 1000 males were calculated. Medicare specialty codes were used to identifythe specialty of the physicians performing the procedures.

RESULTS

PB volume peaked in 2002, when a total of 292,045 were performed in Medicare patients. A generally downward trend then followedin subsequent years, reaching 165,382 in 2013 (-43%). The rate of PBs per 1000 male Medicare beneficiaries was 17.4 in 2002,decreasing to 9.6 in 2013. In that last year, urologists performed 87% of the biopsies, while radiologists performed 0.6%. Most ofthe rest were done in independent diagnostic testing facilities, in which the provider specialty could not be determined. TRUSvolume peaked in 2006 at 318,518, then declined in subsequent years to 214,980 in 2013 (-33%). In that last year, urologistsperformed 90% of TRUSs, while radiologists performed 4%. The remaining 6% were performed by physicians in various otherspecialties.

CONCLUSION

The use of both PB and TRUS has declined substantially in recent years. This appears to reflect a more conservative approach toscreening for PCa, which in turn has resulted from the extensive debate about the risks, costs, and benefits of identifying andtreating the disease.


Physicians are now performing fewer procedures relating to prostate cancer diagnosis.

ParticipantsAlexander M. Norbash, MD, Boston, MA (Presenter) Co-founder, Boston Imaging Core Laboratories, LLC; William T. Yuh, MD, Seattle, WA (Abstract Co-Author) Nothing to DiscloseE. Kent Yucel, MD, Boston, MA (Abstract Co-Author) Nothing to DiscloseElvira V. Lang, MD, Brookline, MA (Abstract Co-Author) Founder and President, Hypnalgesics, LLC; Stephen Pauker, MD, Boston, MA (Abstract Co-Author) Nothing to DiscloseAmna A. Ajam, MBBS, Little Rock, AR (Abstract Co-Author) Nothing to DiscloseGheorghe Doros, Boston, MA (Abstract Co-Author) Nothing to DiscloseNina A. Mayr, MD, Seattle, WA (Abstract Co-Author) Nothing to Disclose

PURPOSE

The throughput efficiency of high cost imaging services such as Magnetic Resonance Imaging (MRI) has major impact to thefinancial status of the imaging service, particularly given decreasing overall diminishing healthcare margins. We evaluated whether asimple and inexpensive calmative training to the imaging staff team as a cost-effective way to improve the throughput and impactthe financial bottom line.


A total of 97,712 patient visits from 3 tertiary academic medical centers participated, including 49,733 visits during one-year periodprior to the calmative training and 47,979 one-year after training. The center's MRI teams received calmative skill training withadvanced communication and calmative techniques through onsite proctoring, and additional education using case-basedsimulations with scenarios requiring calmative interventions and utilizing electronic educational tools. The study's incompletion rateand patient no-show rate during-year intervals before and after training were compared using two-sided chi-square tests forproportions at a 0.05 significance level.

RESULTS

Despite variations in the patient population at the different sites with differing baseline no-show rates (ranged 5-19.4%) and studyincompletion rates (ranged 0.8-6.9%) prior to training, the combined patients data showed significant (p<0.0001) improvement ofpatient throughput with calmative training. Based upon the one-year data intervals compared before and after training, no-showrates decreased from 11.2% to 8.7% and incompletion rates decreased from 2.3 to 1.4% for all show-up patients. Additonally,increasingly lengthy and complex studies such as cardiac, whole body, or combined imaging studies were performed without anincrease in no-show or incompletion rates following calmative training.

CONCLUSION

The results suggest that calmative training of the imaging support staff can significantly improve the no-show and incompletionrates of the MRI service, thereby improving the throughput and utilization of high-value and expensive imaging modalities such asMRI which happens to have offputting physical features including noise and a constrained bore.


Calmative training of supportive staff can significantly improve the no-show and incompletion rates of the MRI service, improvingthroughput and resource use without added capital budget investment.

RC623A MRI Safety - Rules, Regulations, and Concepts

RC623B MRI Safety of Deep Brain and Other Simulators

RC623

MR Safety I

Thursday, Dec. 3 8:30AM - 10:00AM Location: S105AB

NR MR PH SQ



ParticipantsJoel P. Felmlee, PhD, Rochester, MN (Director) Nothing to Disclose

Sub-Events

ParticipantsKarl Vigen, PhD, Madison, WI (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Understand safety issues in MRI, particularly those caused by the main magnetic field, magnetic field gradients, and transmit RF.2) Understand guidance from the ACR, and governmental regulations designed to address these issues. 3) Describe the importanceof an MR Safety program including comprehensive patient screening in the clinical setting. 4) Briefly address safety issues regardingMRI contrast agents.

ParticipantsYunhong Shu, PhD, Rochester, MN (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Describe various types of neurostimulators and their clinical applications. 2) Understand the underlying MR physics associatedwith the risks of scanning patients with neurostimulators. 3) Learn the precaution steps to ensure the safety of the patient withneurostimulators during MR scanning.

ABSTRACT

The demands and applications for neurostimulators continue to increase as the technology advances. MRI is an importantdiagnostic tool for postoperative evaluation and potential future workup. The presence of the neurostimulator poses potentialsafety risks in the MR scanning environment. By observing certain precautions, MRI can be performed with an extremely low risks. Itis important to follow the manufactures' MRI guidelines to ensure the safety of the patients and continuous functioning of thedevice.

RC651-01 Minimizing Sedation in Pediatric Neuroimaging

Thursday, Dec. 3 8:30AM - 8:50AM Location: S102D

RC651-02 Comparison of Non-sedated Brain MRI and CT for the Detection of Acute Traumatic Injury inChildren Less than 5 Years Old


RC651

Pediatric Series: Optimizing Acquisition and Achieving Efficiency in Pediatric Imaging

Thursday, Dec. 3 8:30AM - 12:00PM Location: S102D

MR PD SQ



ParticipantsDonald P. Frush, MD, Durham, NC (Moderator) Nothing to DiscloseAliya Qayyum, MBBS, Houston, TX (Moderator) Nothing to DiscloseRajesh Krishnamurthy, MD, Houston, TX (Moderator) Research support, Koninklijke Philips NV; Research support, ToshibaCorporationA. James Barkovich, MD, San Francisco, CA (Moderator) Nothing to Disclose

LEARNING OBJECTIVES

ABSTRACT

This session will focus on the importance of minimizing general endotracheal anesthesia in children and discuss recent papers thathighlights risks in children. It will discuss techniques for minimizing the use of sedation and intubation in pediatric imaging, includinguse of abbreviated protocols for common indications, feed and wrap techniques, and state of the art MR sequences for free-breathing 2-D and 3-D acquisition of morphology , function and flow in children.

Sub-Events

ParticipantsA. James Barkovich, MD, San Francisco, CA (Presenter) Nothing to Disclose

LEARNING OBJECTIVES


ABSTRACT

There are several keys to minimizing sedation in Pediatric Neuroimaging. Most important are targeting the study to obtaining thespecific answer requested by the referring clinician, and obtaining the data as efficiently as possible by using sequences that willanswer the question in the shortest time. The second is that the strategy changes depending upon the age of the patient:neonates most often can be scanned without sedation; a relatively short scan can be performed on infants by the 'feed andswaddle' method, and older children (6 years and above) can very frequently be studied without sedation if training and/or movies(to give them focus) are used. For neonates requiring a relatively short scan (is injury present or not), a useful technique is to feedthe baby immediately before the procedure and then wrap them in a vacuum bean bag or wrap (swaddle) them in a blanket.Reducing noise by use of ear muffs, insulating the inner bore of the magnet, parallel imaging or ultra-short TE sequences can help,as can retrospective motion correction. Infants can also be scanned using feed and swaddle; it helps to do the scan during theirnap time, if possible, and to take them to a quiet room with a parent so that they are asleep when placed in the MRI scanner. Usequiet sequences early in the study, saving the noiser ones for the end. Again, use of parallel imaging or ultra-short TE sequenceshelps to reduce noise. It is very difficult to image children between ages of 1 and 6 years without sedation. The goal is to scanefficiently. for older children, a training session before the scan to reduce anxiety is useful. Use of a system that allows the child towatch a movie of their own choice is very helpful as well.

ParticipantsJoseph Y. Young, MD, Boston, MA (Presenter) Nothing to DiscloseAnn-Christine Duhaime, MD, Boston, MA (Abstract Co-Author) Nothing to DisclosePaul A. Caruso, MD, Boston, MA (Abstract Co-Author) Nothing to DiscloseAri Cohen, MD, Boston, MA (Abstract Co-Author) Nothing to DiscloseJean Klig, MD, Boston, MA (Abstract Co-Author) Nothing to DiscloseSandra Rincon, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose

PURPOSE

The 2014 ACR Appropriateness Criteria consider CT the first line study for acute intracranial injury in children because of its wideavailability, detection of acute hemorrhage, and lack of sedation. A tailored MRI study with rapidly acquired sequences can obviatethe need for sedation and radiation. We compared the sensitivity of rapid non-sedated brain MRI and CT for the detection oftraumatic head injury in young children.


We reviewed a consecutive series of children less than 5 years old who presented to our ED during a 5 year period with headtrauma and received a non-sedated brain MRI and CT within 24 hours of injury. Most MRI studies were limited to triplane T2 andsusceptibility sequences. A few studies had additional sequences, including FLAIR and DWI, if clinically indicated and if the patientcould tolerate a longer exam. Two neuroradiologists concurrently reviewed the MRI and CT studies on separate days and assessed

RC651-03 Quantifying the Radiation Dose Savings of Implementing an Ultra-Fast Brain MRI Protocol forChildren with Hydrocephalus


RC651-04 Silent MRI Reduces Children's Risk by Decreasing Need for Additional Sedation


for the following five findings: fracture, epidural hematoma (EDH)/subdural hematoma (SDH), subarachnoid hemorrhage (SAH),intraventricular hemorrhage (IVH), and parenchymal injury.

RESULTS

27 patients met inclusion criteria with a mean age of 21 months. A total of 49 abnormalities was noted in 25 patients, with 21patients having intracranial findings. There was 79% agreement between the two modalities assessing for the presence of fracture,EDH/SDH, SAH, IVH, and parenchymal injury for each patient. CT missed 13 findings which included 6 EDH/SDH, 5 SAH, and 2parenchymal injuries. MRI missed 13 findings which included 10 non-displaced fractures (of 17 fractures), 2 small EDH/SDH, and 1SAH. The CT was negative for 4 patients in whom the MRI demonstrated intracranial findings (4 EDH/SDH, 2 SAH, 2 parenchymal).MRI was negative in 1 patient for whom CT had intracranial findings (1 small EDH/SDH).

CONCLUSION

Non-sedated MRI is at least as sensitive as CT for the detection of intracranial injury in young children presenting with acute headtrauma, though missed 10 of 17 fractures. Non-sedated MRI may be a useful alternative to CT in select populations. Low-dose CTmay be obtained when fracture detection is clinically indicated.


Non-sedated MRI may be a useful alternative to CT for young children presenting with acute head trauma, thereby avoidingassociated radiation risks.

ParticipantsDaniel Durand, MD, Baltimore, MD (Presenter) Stockholder, Evolent Health, LLC; Advisor, National Decision Support Company;Advisor, Radiology Response; Founder, am-I-ok.comMahadevappa Mahesh, MS, PhD, Baltimore, MD (Abstract Co-Author) Author with royalties, Wolters Kluwer nvThierry Huisman, MD, Baltimore, MD (Abstract Co-Author) Nothing to DiscloseEric M. Jackson, MD, Baltimore, MD (Abstract Co-Author) Nothing to DiscloseAllison Greene, BS, Baltimore, MD (Abstract Co-Author) Nothing to DiscloseSiyuan Cao, BS, Baltimore, MD (Abstract Co-Author) Nothing to DiscloseAylin Tekes, MD, Baltimore, MD (Abstract Co-Author) Nothing to Disclose

PURPOSE

Children with shunted hydrocephalus frequently require neuroimaging to evaluate shunt function. For a number of practical reasonsincluding length of study, need for sedation, and scanner availability, CT is favored over MRI at most centers. Children are alsomore susceptible than adults to radiation-induced cancer, with empirical evidence showing that the pediatric brain is particularlyprone to cancers associated with CT. Previous reports have shown that ultrafast MRI can be used in place of head CT forevaluating hydrocephalus without any loss of sensitivity or specificity. The purpose of our study was to quantify the net radiationdose savings associated with transitioning from head CT to ultrafast brain MRI in this population.


An ultra-fast brain MRI protocol without sedation/anesthesia with an average scan time under 5 min was implemented for childrenwith shunted hydrocephalus. A RIS query was designed to extract all neuroimaging orders for obstructive hydrocephalus for twotime periods: a 3 month baseline period and a 6 month post-intervention period. The number of CTs performed per month wasdetermined for each period and used to determine the number of cases avoided per month. Size-specific dose estimates for 30patients in the baseline group were determined using measurements of anteroposterior and mediolateral head diameter as well asCTDIvol and scan length data stored on the PACS. The average dose per case and the CT avoidance rate were used to yieldestimates of the annual radiation dose savings to the population in units of size-specific dose estimate (mGy) and age-adjustedeffective dose (mSv).

RESULTS

The pre- and post-intervention imaging rates were 20.7 and 8.5, yielding a CT avoidance rate of 12.2 per month. The mean size-specific dose estimate (Figure 1) per CT was 30.40 mGy and the mean age-adjusted effective dose was 1.76 mSv. The annualpopulation radiation dose savings was 4,450 mGy and 258 mSv.

CONCLUSION

Implementing a standard protocol to encourage the use of ultrafast brain MRI in place of head CT significantly reduced the annualradiation dose to pediatric patients imaged for hydrocephalus.


Our results show the benefit of using ultrafast brain MRI in place of head CT for suspected hydrocphalus. The method used here toquantify population radiation dose savings can be used more generally to highlight the value that radiologists and medical physicistsbring to care pathway redesign.

ParticipantsChisato Matsuo, MD, Suita, Japan (Abstract Co-Author) Nothing to DiscloseYoshiyuki Watanabe, MD, PhD, Suita, Japan (Abstract Co-Author) Nothing to DiscloseHisashi Tanaka, MD, Suita, Japan (Abstract Co-Author) Nothing to DiscloseHiroto Takahashi, MD, Suita, Japan (Abstract Co-Author) Nothing to DiscloseAtsuko Arisawa, MD, Suita, Japan (Abstract Co-Author) Nothing to DiscloseNoriyuki Tomiyama, MD, PhD, Suita, Japan (Abstract Co-Author) Nothing to Disclose

RC651-05 High-pitch CT of the Chest in Newborns and Infants: Is Sedation or Breath-hold Still Necessary?


Eri Yoshioka, MD, Matsubara, Japan (Presenter) Nothing to DiscloseShin Nabatame, Suita, Japan (Abstract Co-Author) Nothing to DiscloseSayaka Nakano, Suita, Japan (Abstract Co-Author) Nothing to DiscloseMatthew W. Lukies, MBBS, Osaka, Japan (Abstract Co-Author) Nothing to Disclose

PURPOSE

Sedated children often wake up during magnetic resonance imaging (MRI) and additional sedatives are needed; the acoustic noiseduring the MR scanning might be the main cause of this. We hypothesized that silent MRI would decrease the frequency of arousaland additional administration of sedatives during examinations when compared with conventional MRI.


Twenty-eight children (M:F=18:10, age 13 months-8 years, mean 4.3 years, median 5 years) who underwent silent brain MRI fromJanuary to August in 2014 were retrospectively compared to 26 children (M:F=10:16, age 4 months-8 years, mean 4.0 years,median 3 years) who underwent conventional brain MRI from May to December in 2013 with the same 3T MR unit. The pediatricianadministered intravenous sedatives including thiopental to all patients. Data from the medical chart of each patient was reviewedas follows: administered sedatives, doses, and need for additional intravenous injections during examinations. Unpaired t-test wasused in the statistical analysis of the initial dose of thiopental. The need for additional sedation was assessed by Fisher's exacttest.

RESULTS

The mean initial dose of thiopental was 3.1 mg/kg for conventional MRI group and 3.3 mg/kg for silent MRI group. There was nosignificant difference between the two groups (p=0.55). Ten out of twenty-six patients (38%) woke up during conventional MRIand additional sedatives were needed. On the other hand, three out of twenty-eight patients (11%) woke up during silent MRI andrequired additional sedatives. There was a significant difference between the two groups (p=0.02).

CONCLUSION

Silent MRI decreased the frequency of arousal and additional intravenous sedation during examinations. This can reduce patient riskand may possibly reduce the amount of time required for examinations.


Silent MRI can reduce children's risk by decreasing the need for additional sedation and may possibly reduce the amount of timerequired for examinations; silent MRI is recommended in routine brain evaluation for children.

ParticipantsIlias Tsiflikas, MD, Tuebingen, Germany (Abstract Co-Author) Nothing to DiscloseMatthias Teufel, Tuebingen, Germany (Abstract Co-Author) Nothing to DiscloseMichael Esser, MD, Tuebingen, Germany (Abstract Co-Author) Nothing to DiscloseSergios Gatidis, MD, Tubingen, Germany (Abstract Co-Author) Nothing to DiscloseInes Ketelsen, Tuebingen, Germany (Abstract Co-Author) Nothing to DiscloseSabrina Fleischer, MD, Tuebingen, Germany (Abstract Co-Author) Nothing to DiscloseKonstantin Nikolaou, MD, Tuebingen, Germany (Abstract Co-Author) Speakers Bureau, Siemens AG Speakers Bureau, Bracco GroupSpeakers Bureau, Bayer AGJuergen F. Schaefer, MD, Tuebingen, Germany (Presenter) Nothing to Disclose

PURPOSE

To evaluate feasibility and image quality of high-pitch computed tomography of the chest without sedation or breath-hold innewborns and infants under the age of 12 months.


IRB waived informed consent and approved this retrospective, HIPAA-compliant study. 88 patients (48 boys, age 153 ± 103 days)received 123 high-pitch CT examinations (HPCT) of the chest between October 2010 and December 2014. All examinations werescanned in free breathing. 84 HPCT were without sedation or general anesthesia, whereas 39 examinations were performed ingeneral anesthesia because of patients' clinical condition. 84/123 HPCT were contrast-enhanced. Tube voltage and current weredetermined according to our institutional weight-adopted standard scanning protocol (70-100 kV; 6 - 80 mAs). Image quality wasevaluated by two experienced pediatric radiologists with respect to typical artifacts arising from movement, breathing or pulsationof the heart or pulmonary vessels (0 - no; 1 -moderate; 2 - severe artifacts). Effective dose (E eff ) was estimated according tothe European Guidelines on Quality Criteria for Multislice Computed Tomography.

RESULTS

All examinations were performed without the notice of moving artifacts. In awake patients there was a higher frequency ofmoderate breathing artifacts (19/84 vs. 1/39, p<0.01) and pulsation artifacts (19/84 vs. 8/39, p=0.79), but in no examinationsevere artifacts could be detected.The overall dose was very low (0.52 ± 0.30 mSv). As expected the estimated E eff was higherin contrast-enhanced examinations than in non-enhanced scans (0.58 ± 0.33 vs. 0.40 ± 0.18 mSv). Further E eff was higher inexaminations in general anesthesia (0.61 ± 0.42 vs. 0.48 ± 0.22 mSv), what might be explained due to a higher rate of contrast-enhanced scans (79% vs. 63%) in this patient group.

CONCLUSION

High-pitch scanning allows the examination of the chest in newborns and infants without sedation or breath-hold in sufficient imagequality and with low effective doses.


Newborns and infants undergoing chest CT can be examined without sedation or breath-hold without significant loss in imagequality.

RC651-06 The Optimal Scanning Protocol of Prospective ECG-triggering DSCT Thoracic Angiography in Childrenwith Tetralogy of Fallot


RC651-07 Minimizing Sedation and Radiation in Pediatric Cardiovascular Imaging


RC651-08 Minimizing Sedation in Pediatric Abdominal and Musculoskeletal MRI


RC651-09 High-pitch Low-dose Whole Body CT for the Assessment of Ventriculo-peritoneal Shunts in PediatricPatients: An Experimental ex-Vivo Study in a Rabbit Model


ParticipantsYanhua Duan, MD, Jinan, China (Presenter) Nothing to DiscloseXiming Wang, Jinan, China (Abstract Co-Author) Nothing to Disclose

PURPOSE

To evaluate the effect of 4 different scanning protocols (bolus-tracking technique, test-bolus technique, fixed delay time techniqueand "manual" bolus-tracking technique) on image quality and effective dose of prospective ECG-triggering DSCT thoracicangiography in children with TOF.


Eighty consecutive children (48 boys; mean age of 3.5 years; mean heart rate: 97 bpm) with known or suspected TOF wereenrolled between December 2008 and September 2014 in our institute. All children underwent prospective ECG-triggering DSCTthoracic angiography.All patients were assigned to 4 groups randomly according to the different enhanced scanning protocols:bolus-tracking technique (n=20, group A), test-bolus technique (n=20, group B), fixed delay time (25s) technique (n=20, group C)and "manual" bolus-tracking technique (place the region of interest in the background at the level of four-chamber, a monitoringscanning started at 18s after injection, the acquisition was manually triggered at the moment that the contrast medium artifact inthe right atrium began to disappear) (n=20, group D).Subjective image quality was independently assessed by two radiologists. Thetotal effective dose (including premonitoring, monitoring scanning and angiographic scanning) were calculated.

RESULTS

All prospective ECG-triggering DSCT angiographic scans were successful. The image quality scores of groups A, B, C and D were3.20±1.06, 3.10±1.12, 3.40±1.30, 4.15±0.81, respectively, there were significant differences among the four groups (p=0.012).The total effective dose of groups A, B and C were (0.40±0.06)mSv, (0.56±0.14)mSv, (0.38±0.06)mSv, (0.39±0.09)mSv,respectively, there were significant differences among 4 groups (p=0.023).

CONCLUSION

The scanning protocol has a significant impact on the image quality with a significantly different radiation dose. Considered theimage quality and radiation dose together, the optimal scanning protocol for patient with TOF was the "manual" bolus-trackingtechnique.


"Manual" bolus-tracking technique is an excellent scanning protocol for TOF patients.

ParticipantsRajesh Krishnamurthy, MD, Houston, TX (Presenter) Research support, Koninklijke Philips NV; Research support, Toshiba Corporation

LEARNING OBJECTIVES


ParticipantsShreyas S. Vasanawala, MD, PhD, Palo Alto, CA (Presenter) Research collaboration, General Electric Company; Consultant, Arterys;Research Grant, Bayer AG;

LEARNING OBJECTIVES


ABSTRACT

Sedation for pediatric MRI has multiple disadvantages. It confers risk of adverse events for what is an otherwise non-invasiveprocedure. Additionally, sedation contributes to cost, makes exam scheduling complex, and leads to inefficient imaging utilization.This presentation will present some approaches to reduce the incidence, duration, and depth of sedation for pediatric abdominaland musculoskeletal indications.An overview of child developmental approaches that reduce the incidence of sedation will be given.Then an approach for compact protocols to minimize duration of sedation will be presented. This will be followed by discussion ofmethods of managing respiratory motion artifacts without periods of suspended respiration, thus reducing depth of anesthesia.

ParticipantsAhmed E. Othman, MD, Tuebingen, Germany (Presenter) Nothing to DiscloseSaif Afat, MD, Aachen, Germany (Abstract Co-Author) Nothing to DiscloseRastislav Pjontek, Aachen, Germany (Abstract Co-Author) Nothing to DiscloseMarc A. Brockmann, MD, Luebeck, Germany (Abstract Co-Author) Nothing to DiscloseOmid Nikoubashman, Aachen, Germany (Abstract Co-Author) Nothing to Disclose

RC651-10 Application of T1-weighted BLADE Sequences to Abdominal MR Imaging of Young Children:Comparison with Turbo Spin Echo Sequence


RC651-11 Performing Screening Lumbar Spine MRIs in Infants without Sedation - The L-Spine Feed and Sleep


Konstantin Nikolaou, MD, Tuebingen, Germany (Abstract Co-Author) Speakers Bureau, Siemens AG Speakers Bureau, Bracco GroupSpeakers Bureau, Bayer AGMartin Wiesmann, MD, Munich, Germany (Abstract Co-Author) Nothing to Disclose

PURPOSE

To assess the sensitivity of whole-body Low-Dose CT (LD-CT) in pediatric patients, regarding the detection of ventriculo-peritonealshunt (VP-shunt) complications in comparison to radiographic shunt series (SS), with special regards to radiation exposure, using anex vivo rabbit model.


In a first step, an optimized low dose CT imaging protocol, with low tube voltages (70 kVp and 80 kVp) was assessed on a 16 cmphantom regarding signal-to-noise ratio (SNR) and radiation dose (with and without iterative reconstruction). After defining the CTprotocol with the lowest possible radiation dose, 12 VP-shunts were implanted in 6 rabbit cadavers (weight, 4 - 6 kg). 24mechanical complications (extracranial and extraperitoneal malpositioning, breakages, disconnections) were induced in 6 VP-shunts.LD-CT scans with the lowest possible radiation doses (80 kVp; 4 mAs) as well as conventional SS were acquired. Blinded readingson image quality and diagnostic accuracy regarding shunt complications as well as radiation dose estimations were performed.

RESULTS

For the detection of shunt complications, LD-CT yielded a sensitivity of 1.0 for both readers. SS yielded a sensitivity of 0.79 forreader A and 0.71 for reader B with moderate agreement (kappa=0.56) (Figure). No false positive findings were registered. Meaneffective radiation doses for LD-CT were as low as 0.069 ± 0.003 mSv and therefore comparable to reported doses for SS (0.047mSv - 0.086 mSv).

CONCLUSION

LD-CT allows accurate detection of VP-shunt complications in pediatric patients with higher sensitivity than SS and comparably lowradiation exposure. Thus, LD-CT provides a potentially superior alternative to radiographic shunt series for imaging VP-shunts.


The improvement of accurate diagnostic tools such as LD-CT might potentially reduce time-to-diagnosis and patient turnaroundtime and might therefore improve the poor outcome and quality of life for children with shunted hydrocephalus.

ParticipantsKyusung -. Choi, MD, Seoul, Korea, Republic Of (Presenter) Nothing to DiscloseYoung Hun Choi, MD, Seoul, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseJung-Eun Cheon, MD, Seoul, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseJi-Eun Park, Seoul, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseHyun Suk Cho, Seoul, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseYu Jin Kim, MD, Seoul, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseWoo Sun Kim, MD, Seoul, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseIn-One Kim, MD, Seoul, Korea, Republic Of (Abstract Co-Author) Nothing to Disclose

PURPOSE

To evaluate the usefulness of T1-weighted BLADE sequences for axial T1-weighted abdominal imaging in small children who cannothold their breath.


Two different BLADE sequences with (IR-BLADE) and without inversion pulse (BLADE) were compared to TSE with six number ofsignal acquired (NSA) in fifteen consecutive pediatric patients (mean age of 4.4 years, range 0.5-8 years) who were incapable ofholding their breath. The overall image quality, motion artifact, radial artifact, sharpness of hepatic vessels, renal corticomedullarydifferentiation and lesion conspicuity were retrospectively assessed by two radiologists in a qualitative manner, using four or five-point scaled scoring systems. Signal variations of each sequence were measured in the liver, muscle and air for quantitativecomparison. The acquisition times of three sequences were compared.

RESULTS

IR-BLADE and BLADE showed improved overall image quality and reduced motion artifact compared with TSE (p<0.01). IR-BLADEshowed better edge sharpness of hepatic vessels and corticomedullary differentiation, compared with both BLADE and TSE(p<0.001). Radial artifacts were only observed on IR-BLADE and BLADE. In seven patients with lesions, IR-BLADE showed improvedlesion conspicuity, compared with both BLADE and TSE (p=0.023). Both IR-BLADE and BLADE showed decreased signal variation inthe liver, muscle and increased signal variation in the air, compared with the TSE. The mean acquisition times for IR-BLADE, BLADEand TSE were 3min 47s, 3min 32s, and 3min 26s respectively.

CONCLUSION

Application of BLADE technique with inversion pulse for the T1-weighted MR imaging of the pediatric abdomen resulted in improvedimage quality, tissue contrast and lesion conspicuity with a diminished respiratory motion artifact and a comparable acquisition time,compared with the conventional TSE sequence.


IR-BLADE could be a promising alternative to conventional TSE sequence for T1-weighted abdominal imaging of small children.

RC651-12 A Retrospective Analysis of the Safety and Cost Implications of Pediatric Contrast EnhancedUltrasound in a Single Centre


ParticipantsNicholas V. Stence, MD, Aurora, CO (Presenter) Nothing to DisclosePatrick T. McCormick, MD, Aurora, CO (Abstract Co-Author) Nothing to DiscloseDavid M. Mirsky, MD, Philadelphia, PA (Abstract Co-Author) Nothing to DiscloseLaura Z. Fenton, MD, Greenwood Village, CO (Abstract Co-Author) Nothing to DiscloseJohn D. Strain, MD, Greenwood Village, CO (Abstract Co-Author) Nothing to DiscloseJohn A. Maloney, MD, Denver, CO (Abstract Co-Author) Nothing to DiscloseBrent O'Neill, MD, Aurora, CO (Abstract Co-Author) Nothing to Disclose

PURPOSE

The feed and sleep technique is used in infants to avoid general anesthesia during MRI. The method typically involves fasting aninfant prior to exam, feeding and swaddling immediately before scanning until asleep. This technique is commonly used in children'shospitals for neonatal brain MRI, and has been described in the literature in brain and cardiac MRIs. We describe the application ofthis technique in our institution to outpatient screening lumbar spine MRIs ordered for sacral dimples in children less than 6 monthsof age.


This project was undertaken as an internal quality improvement project and therefore did not require IRB approval. Thedepartmental Montage database (Montage Healthcare Solutions) was queried for the number of outpatient, non-contrast lumbarspine MRI exams performed in infants less than 6 months of age over the last 5 years. The number of exams performed as non-sedated feed and sleeps was extracted.The feed and sleep method is performed as follows: Infants are scheduled for examsbetween 7 p.m. and 9 p.m. Parents are instructed to keep the child awake and fasted for 3-4 hours prior to arrival in thedepartment. On arrival, the MRI technologist aids the parents with swaddling and feeding the infant. Once the child is asleep, theyare placed in the scanner and provided ear protection with both a headset and a Philips foam acoustic shield.

RESULTS

From January 2009 through January 2014, 111 of 342 (32%) of outpatient screening lumbar spine MRIs were successfully performedusing the feed and sleep method, compared to 52 of 98 (53%) exams performed March 2014 through March 2015. The average ageof successful feed and sleep exams in the last year was 3.3 months. Over the last year, approximately 10% of the examsattempted as feed and sleeps required rescheduling with general anesthesia after the attempt was unsuccessful.

CONCLUSION

Our institution was able to avoid the use of general anesthesia in 52 of 98 infants who required a screening lumbar spine MRI forsacral dimples. The successful use of this method has increased over the past 5 years. This is likely due to increased MRItechnologist confidence and skill with the technique, as well as an increasing awareness of this technique among referringclinicians.


Wider application of this technique could lead to a reduction in general anesthesia for this type of exam, leading to decreases incost and risk to the patient.

ParticipantsGibran Yusuf, MBBS, London, United Kingdom (Presenter) Nothing to DiscloseMaria E. Sellars, MD, FRCR, London, United Kingdom (Abstract Co-Author) Nothing to DiscloseAnnamaria Deganello, MD, London, United Kingdom (Abstract Co-Author) Speaker, Bracco GroupDavid O. Cosgrove, MBBCh, FRCR, London, United Kingdom (Abstract Co-Author) Research Consultant, SuperSonic Imagine;Research Consultant, Bracco Group; Speakers Bureau, Toshiba CorporationPaul S. Sidhu, MRCP, FRCR, London, United Kingdom (Abstract Co-Author) Speaker, Bracco Group; Speaker, General ElectricCompany

PURPOSE

There are concerns over increasing use of ionising radiation in children. Contrast enhanced ultrasound (CEUS) offers a cheaperradiation free alternative licensed in adults, widely used in Europe for liver assessment but used "off-label" in non-liver indications.Pediatric CEUS is "off label", and safety has not been assessed. We retrospectively analyse the prevalence of adverse incidents in acohort of paediatric CEUS and investigate the financial implication of subsequent reduced CT and MR imaging.


Pediatric (≤18 yrs) CEUS examinations (January 2008 and March 2015) were analysed. Parental informed consent was obtained andany reaction considered related to the contrast examination was documented in the radiology report, with electronic patientrecords examined for reactions ≤24hrs. Using tariffs calculated from National Institute of Clinical Excellence (UK) analysis; CEUScost ($168) was compared to the cost for CT ($172) and MR ($280) imaging, the normal diagnostic imaging pathway. The possiblereduction in cost when CEUS would have precluded further imaging was calculated.

RESULTS

240 paediatric CEUS were performed (144 male, 96 female, age range 1-18 years). The majority of studies were performed forcharacterising liver lesions (123/240; 51%) and trauma (86/240; 36%), with renal and vascular assessment the remaining. Therewere no immediate adverse reactions. Two patients (2/240; 0.8%) experienced delayed adverse reactions of transient hypertension(n=1) and transient tachycardia (n=1) deemed not due to the underlying disorder; neither were symptomatic.

CONCLUSION

CEUS in children is "off label"; however, our experience shows paediatric CEUS is both safe and can offer a cost-effective imaging

RC651-13 Sonographic Evaluation of MAGEC Growing Scoliosis Rods in Pediatric Patients


RC651-14 Low Dose Pediatric Chest CT: Radiation Dose Comparison of a 70 kVp CT Protocol and a 100 kVpProtocol Using a Tin Filter for Spectral Beam Shaping


modality.


CEUS in paediatrics offers a safe, cost effective alternative to MR and CT imaging in a variety of settings without the risk ofionising radiation, iodinated contrast or risks of sedation which may otherwise be needed.

ParticipantsSara M. O'Hara, MD, Cincinnati, OH (Presenter) Author, Reed Elsevier; Stockholder, Reed Elsevier; Speakers Bureau, ToshibaCorporation; Medical Advisory Board, Toshiba CorporationPeter F. Sturm, MD, Cincinnati, OH (Abstract Co-Author) Nothing to DiscloseSarah E. Gilday, Cincinnati, OH (Abstract Co-Author) Nothing to Disclose

PURPOSE

Adjustable, magnetically controlled "growing" scoliosis rods (MAGEC rods) are increasingly used in pediatric patients, and requireperiodic adjustments and confirmation of lengthening following this non-invasive procedure. Previously, adjustable rods requiredopen surgical procedures for lengthening. The purpose of our study was to determine if these MAGEC rods could be adequatelyvisualized and measured with ultrasound, thereby minimizing radiation exposure from serial spine X-rays.


All patients with recently implanted MAGEC rods were examined with ultrasound before and after their first transcutaneous magneticrod lengthening procedures. Measurements obtained sonographically were compared with baseline scoliosis X-rays and the lengthprogrammed into the magnetic motor used to extend the rod. Measurements will also be compared with scoliosis X-rays obtainedonce or twice each year.

RESULTS

12 patients have been studied to this point (3 month period) - 6 female, and 6 male, between 6 and 10 years of age. All of theMAGEC rod components including extension motors and expandable rod segments were well visualized sonographically before andafter lengthening procedure. All of the patients showed good correlation between post-op scoliosis measurements and first, pre-lengthening ultrasound measurements. 4 of the 13 patients rods showed less lengthening than expected based on the lengthprogrammed into the magnetic motor driver. All patients will be re-imaged in the next few months to quantify measurementreliability and compare with expected extension parameters.

CONCLUSION

MAGEC rods can be reliably imaged with ultrasound before and after transcutaneous lengthening procedures, thereby reducingradiation exposure. In addition, the ultrasound may offer additional confidence that the rods have in fact extended the lengthprogrammed into the magnetic motor.


Ultrasound should be the preferred method for serial imaging of MAGEC adjustable scoliosis rods in pediatric patients to minimizeexposure to ionizing radiation.

ParticipantsMeike Weidner, Mannheim, Germany (Presenter) Nothing to DiscloseThomas Henzler, MD, Mannheim, Germany (Abstract Co-Author) Nothing to DiscloseHolger Haubenreisser, Mannheim, Germany (Abstract Co-Author) Speaker, Siemens AG; Speaker, Bayer AGMathias Meyer, Mannheim, Germany (Abstract Co-Author) Speaker, Siemens AG; Speaker, Bracco GroupSonja Sudarski, MD, Mannheim, Germany (Abstract Co-Author) Nothing to DiscloseStefan O. Schoenberg, MD, PhD, Mannheim , Germany (Abstract Co-Author) Institutional research agreement, Siemens AGWolfgang Neff, MD, PhD, Alzey, Germany (Abstract Co-Author) Nothing to DiscloseClaudia Hagelstein, MD, Mannheim, Germany (Abstract Co-Author) Nothing to Disclose

PURPOSE

With the introduction of 3rd generation dual-source CT two competetive techniques for further radiation dose reduction becameclinically available. On the one hand the CT peak tube voltage can be decreased down to 70 kVp whereas on the other hand 100kVp imaging can be combined with a dedicated 0.6 mm tin (Sn) filter behind the x-ray tube in order to filter-out low energyphotons. We aimed to compare radiation dose in pediatric chest CT scans between 70kV and 100kVp-Sn acquisitions.


All chest CT examinations were performed on a 3rd generation 2 x 192 slice dual source system (Somatom Force, SiemensHealthcare, Germany) using a pitch factor of 3.2 and automatic tube current modulation without any sedation. In total, 46examinations were included in this study (mean age 5.8±5.9 years, 70kV n=26; 100Sn n=20). Radiation dose was compared by theCT dose index (CTDIvol), effective dose (ED) after ICRP guideline 103 and organ doses. The latter were calculated withcommercially available software (Radimetrics, Bayer, Germany). Signal to noise ratio (SNR) was calculated for lung tissue.

RESULTS

CTDIvol was significantly lower in the 100 kVp-Sn examinations (0.26±0.13 mGy) when compared to 70kVp (0.81±0.73 mGy;p<0.0001). Accordingly, mean effective dose was significantly reduced when using 100 kVp-Sn (0.30±0.09 mSv) compared to70kVp acquisitions (0.84±0.54 mSv; p<0.0001; Fig. 1). Organ doses were also significantly lower with the 100 kVp-Sn protocol

RC651-15 Comparative Assessment of New Generation CT Scanners for Pediatric Applications

Thursday, Dec. 3 11:40AM - 12:00PM Location: S102D

compared to the 70kVp protocol, e.g. breast dose with 100 kVp-Sn was 0.49 mSv vs. 1.57 mSv with 70kV, resulting in a factor of3.2 (p<0.0001). SNR in lung tissue was comparable between both examination protocols (p=0.1).

CONCLUSION

Both, tube voltage reduction to 70kV and Sn-filter based spectral shaping at 100kVp allow to acquire pediatric chest CT scans atsub-mSv dose levels. In direct comparison 100Sn even performs at lower dose levels. Consequently, chest CT scans withoutcontrast agent should be performed with this technique.


Pediatric chest CT scans can be performed with sub-mSv dose levels when using either 70kVp tube voltage or spectral beamshaping with an additional tin filter at 100kVp (100 kVp-Sn). All pediatric chest CT scans without contrast agent should be acquiredwith 100 kVp-Sn.

ParticipantsWhal Lee, MD, PhD, Seoul, Korea, Republic Of (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Reviewing the mechanical development of CT machines. 2) Comparative Assessment of New Generation CT Scanners. 3) Knowingnew applications and new pitfalls in scanning in children.

ABSTRACT

Computed tomography scanner was introduced at 1974. The scan was sequential at that time, in which the gantry made acomplete rotation to acquire an image of a slice.This conventional step-and-shoot technique needed a long scan time because ofthe interscan delays between the slices. In the late 1980's and early 1990's, spiral scanners were introduced. The gantrycontinuously rotates, while the table is continuously moving. This spiral scanning allowed fast and continuous acquisition of acomplete set of volume image data. In 1998, multi-detector technology was announced with first 4 channels MDCT. Since then, thenumber of rows of detectors has ever increased, 8, 16, 64, 128 and reaching 320 in 2008. The fast rotation speed of gantry isessential for imaging of an organ. The gantry rotation times have been fast up to 270 msec. There is a machine of two X-ray tubeand two detector systems in a gantry which allow only one forth rotation enough to make a slice of image and high pitch fastscanning. The wide detector CT and high pitch scanning is fascinating imaging method for child to overcome motion artifact andreducing radiation dose. However, we have to know the pitfalls in these new scan mode. The overscan range is larger than that ofpast and wide beam angle of wide detector scanner gave us geometrical unused radiation and that cannot be neglected. In thislecture we will review the mechanical development of CT machines and new applications and new pitfalls in scanning in children.

Active Handout:Whal Lee

http://abstract.rsna.org/uploads/2015/14044487/RC651-15 new CT ped app handout.pdf

RC654A Structured Reporting

RC654B Improving the Quality of Follow-up Recommendations

RC654C Enabling Evidence-based Recommendations in Radiology Reports

RC654

Decision Support for Radiologists at the Time of Reporting

Thursday, Dec. 3 8:30AM - 10:00AM Location: S103CD

IN SQ


ParticipantsCharles E. Kahn JR, MD, MS, Philadelphia, PA, ([email protected]) (Moderator) Nothing to Disclose

Sub-Events

ParticipantsCharles E. Kahn JR, MD, MS, Philadelphia, PA, ([email protected]) (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Describe the RSNA's initiative to create a repository of radiology report templates. 2) Explore new information standards forrepresenting and exchanging report templates. 3) Discuss how report templates can increase compliance with practice guidelines.4) Describe new opportunities to incorporate decision support into radiology reporting.

Honored Educators


Charles E. Kahn JR, MD, MS - 2012 Honored Educator

ParticipantsTarik K. Alkasab, MD, PhD, Boston, MA, ([email protected]) (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Describe how informatics tools such as computer-assisted reporting/decision support can lead to more consistent radiologistrecommendations for follow-up. 2) Describe how informatics tools will permit creation of 'structured recommendations'. 3) Discusshow these 'structured recommendations' can be used by downstream informations systems.

ParticipantsV. Anik Sahni, MD, Boston, MA (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Describe the importance of evidence-based recommendations in radiology reports. 2) Explore the IT solutions available tointegrate evidence-based recommendations into radiology reports. 3) Discuss tools available to monitor consistency and complianceof recommendations.

SSQ11-01 Informatics Keynote Speaker: Role of Informatics in Quality

Thursday, Dec. 3 10:30AM - 10:40AM Location: S403A

SSQ11-02 How I Missed Your Cancer? An Eye-Tracking Study of Radiological Error in the Detection of LungNodules


SSQ11-03 Scanning Clinical Security Worldwide: Maps and Country Ratings

SSQ11

ISP: Informatics (Quality and Safety)

Thursday, Dec. 3 10:30AM - 12:00PM Location: S403A

CT MR IN SQ



ParticipantsWoojin Kim, MD, Philadelphia, PA (Moderator) Co-founder, Montage Healthcare Solutions, Inc; Shareholder, Montage HealthcareSolutions, Inc; Board of Directors, Montage Healthcare Solutions, Inc; Advisory Board, Zebra Medical Vision LtdKevin W. McEnery, MD, Houston, TX (Moderator) Advisor, Koninklijke Philips NVKevin L. Junck, PhD, Birmingham, AL (Moderator) Nothing to Disclose

Sub-Events

ParticipantsWoojin Kim, MD, Philadelphia, PA (Presenter) Co-founder, Montage Healthcare Solutions, Inc; Shareholder, Montage HealthcareSolutions, Inc; Board of Directors, Montage Healthcare Solutions, Inc; Advisory Board, Zebra Medical Vision Ltd

Honored Educators


Woojin Kim, MD - 2012 Honored Educator

ParticipantsGregory DiGirolamo, PhD, Worcester, MA (Abstract Co-Author) Nothing to DiscloseZachary Zaniewski, Worcester, MA (Presenter) Nothing to DiscloseMax P. Rosen, MD, MPH, Worcester, MA (Abstract Co-Author) Stockholder, Everest Scientific Inc; Consultant, PAREXELInternational Corporation; Stockholder, Cynvenio Biosystems, Inc; Medical Advisory Board, Cynvenio Biosystems, Inc

PURPOSE

Radiologists may miss findings on ~30% cases. These misdiagnoses can result from visual or cognitive/decision-making errors. Visualerrors may include: Scanning errors-not visually fixating on the region that contains an abnormality. Cognitive/Decision errorsinclude: Decision errors-visually fixating on an abnormality, but declaring it normal, and/or Recognition errors- visually fixating onthe region of an abnormality, but not identifying it. We investigated conscious recognition errors and whether Radiologists mighthave unconscious detection of lung nodules despite no conscious recognition.


6 experienced Radiologists interpreted 18 axial chest CT scans (9 normal and 9 abnormal), each consisting of 200-400 slices. Therewere 16 lung nodules in total across the 9 abnormal CT scans. The presence and location of lung nodules were identified by amouse click. Using an Eye-Link 1000, we tracked the location and duration of eye fixations using an invisible (to the observer) gridon each image. Error rates were calculated as our main index of accuracy, and duration of eye movements in each grid region wereused to determine if there was unconscious detection of a lung nodule.

RESULTS

On average, 8/16 (50%, +/- 9%) lung nodules were consciously identified, and registered by a mouse click. However, even when noconscious detection of the lung nodule was registered, Radiologists made significantly longer fixations to the grid regions where thelung nodules were located, (p< .007). Radiologists fixated longer in the grid region where a nodule was located when compared toany other region in that same image (p< .02), even when the nodule was not consciously detected. Radiologists also fixated longerin the grid region where a lung nodule was present (even when not consciously detected) than any grid region in a normal image,p< .03.

CONCLUSION

Our data suggest that even when not consciously recognized, experienced radiologists unconsciously detect the location of lungnodules.


Many findings missed in clinical practice, may actually be detected unconsciously. The use of eye-tracking, or other technologiesmay improve Radiologists' performance.


SSQ11-04 Institution Certification System for Low-Dose Lung Cancer CT Screening in Japan: Development of aNew Web-based Image Evaluation Function


ParticipantsOleg S. Pianykh, Newton Highlands, MA (Presenter) Nothing to Disclose

Background

The fundamental standards of digital medical data exchange, such as DICOM and HL7, date back to the late 1980s. And althoughthese standards went through countless enhancements, one particular aspect - security -remained virtually untouched. The mainpurpose of our work was to perform the first comprehensive study of clinical security worldwide.

Evaluation

We used DICOM and HL7 association establishment protocols to develop a fast, parallel-processing security-probing application.Testing each IP address for its openness to transmit medical data (with no actual data transferred), the application scanned theentire worldwide space of IP addresses in 3 weeks. Geolocation services were used to map each unsecure IP we identified. As aresult, we compiled a comprehensive map of open clinical servers worldwide, with different levels of security threats.

Discussion

Our scan discovered 2774 DICOM servers worldwide, out of which 719 were open for medical data communications. HL7 resultswere similar. Each protocol was used to categorize our findings by different levels of security threats, and geolocation data - bycountries and regions. As a result, we compiled clinical security ratings per country, per capita, and per IT infrastructure. We alsobuilt the first map of DICOM/HL7 adoption worldwide

Conclusion

Medical data archives, left wide-open to security threats, is by far the most common security problem, which needs to beaddressed with a robust, standardized, and fully implemented solution. Our results demonstrate the full scope of this problem, andthe areas where it needs to be solved first.

ParticipantsRikuta Ishigaki, PhD, Kyoto, Japan (Abstract Co-Author) Nothing to DiscloseYoshihisa Muramatsu, PhD, Kashiwa, Japan (Presenter) Nothing to DiscloseYuichiro Maruyama, MD,PhD, Komoro, Japan (Abstract Co-Author) Nothing to DiscloseIsao Yamaguchi, PhD, RT, Sakai, Japan (Abstract Co-Author) Nothing to DiscloseMichael F. McNitt-Gray, PhD, Los Angeles, CA (Abstract Co-Author) Institutional research agreement, Siemens AG; Researchsupport, Siemens AG; ; ; ; ; Yoshito Tabata, Kyoto, Japan (Abstract Co-Author) Nothing to DiscloseMasato Mori, Kyoto, Japan (Abstract Co-Author) Nothing to DiscloseMasafumi Shinozaki, RT, Tokyo, Japan (Abstract Co-Author) Nothing to DiscloseKouzou Hanai, PhD,RT, Tokyo, Japan (Abstract Co-Author) Nothing to Disclose

Background

In Japan, an institution certification system is being established by the Accreditation Council for Lung Cancer CT Screening. Givenprogress in database systems with a dose index registry (DIR) function known as the combined application dose index (CADI), theCADI system will be used to evaluate both dose and image quality. A special image evaluation function has been developed for thisnew use.

Evaluation

The CADI system consists of a CADI server and clients. Image data and dose information are compiled in DICOM and IHE-REMdatabases. Web-based access to the CADI server is possible from approved CADI clients, permitting image evaluation for lungcancer CT screening. This system was certified as meeting the IHE REM Profile at the NA Connectathon 2013, and the web-basedaccess is WADO compliant.A demonstration study was conducted between January 5 and March 31, 2015. A chest phantomcontaining simulated lesions (LSCT-001, Kyoto Kagaku) was scanned using the CT screening protocols at each institution (16institutions, 22 CT systems). CT images (as a 5 mm-slice and a 1 mm interval) and dose reports were sent to CADI clients andtransferred to the CADI server, and dose information and image interpretation by certified radiologists were analyzed. Thecalculated CTDIvol values were 1.9±0.8 mGy (mean ± SD). The calculated DLP values were 65.1±26.7 mGy (mean ± SD).Thesubmitted phantom images are reviewed for image quality and the detectability of the simulated lesions is assessed. The averagedetected diameter (mean ± SD) was 8.9±0.8 mm for the right lung (Design contrast = 100 HU) and 5.7±0.4 mm for the left lung(Design contrast = 270 HU).

Discussion

It is essential to ensure the appropriate image quality at reduced dose for CT screening in healthy people. Dose and image qualityevaluations were performed from the CADI client on Web, and statistical analyses were performed. This allows standardization of CTscreening across Japan; Institutions certified by the Accreditation Council will be able to provide reliable CT screening services.

Conclusion

We have developed a new web-based image evaluation function for the CADI system to establish an institution certification systemfor lung cancer CT screening.

SSQ11-05 Conventional X-ray Dose Analysis in Pediatrics Patients in Different Hospitals Using a CentralizedElectronic Platform


SSQ11-06 Biometric Patient Identity Verification during Magnetic Resonance Imaging of the Brain Using Multi-planar Reconstruction Scout Image


ParticipantsEduardo Fraile Moreno, MD, PhD, San Sebastian de Los Reyes, Spain (Presenter) Nothing to DiscloseCarlos Benito, Madrid, Spain (Abstract Co-Author) Nothing to DiscloseJose Carmelo Albillos, Alcorcon, Spain (Abstract Co-Author) Nothing to DisclosePatricia Fraga Rivas, MD, Coslada, Spain (Abstract Co-Author) Nothing to DiscloseEsther Dominguez-Franjo, MD, PhD, Madrid, Spain (Abstract Co-Author) Nothing to DiscloseJosefa Galobardes Monge, MD, Parla, Spain (Abstract Co-Author) Nothing to DiscloseTrinidad Villarejo, Parla, Spain (Abstract Co-Author) Nothing to Disclose

Background

Imaging diagnostics studies using Xray modalities are increasing the impact on cumulative doseof irradiation delivered to patients.At the same time, a new legislation (2013/59/Euratom) will be put in place to register dose patient history on his Electronic HealthRecord. Dose is a concern for everybody in healthcare environment and especially sensitive when we speak about dose deliveredtokids.Our objective is to analyze variability on the dose in non-focused pediatric departments and determinate root causes to fixthem.

Evaluation

The analysis for pediatric segment has been done in 6 hospitals connected in the same network The studies have been performed inEmergency departments with the same manufacturer and model of digital Xray equipments and same configuration.Data are storageon real time from modalities to a central server used to analyze them. Data from patient studies were collected over a period of onemonth. They were classified according to patient age (0-1 year; 1-5years; 5-10 years and 10-15 years) and gender. For eachcategory of patient, the most used protocols were evaluated and their associated dose levels were collected. For each protocol, analert threshold was calculatedbased on the usual clinical practice (2 times the percentile median).The root causes were classified(bad patient positioning, bad collimation on patient, pediatrics study protocol not selected, bad protocol selected depending onmorphology) and measured.

Discussion

This analysis demonstrates that 15.28% of the extra dose applied to pediatric population is caused directly by misunderstanding orlack of knowledge of how to handle this type of patients. Most of these mistakes can be fixed by dose education through ChangeAcceleration Process (CAP) to take in account seriously the pediatric segment in radiology studies and specific trainings to remindXray technology basis. Consciousness will be done with explanations of dose effect on kids (stochastics and determinists effects)

Conclusion

Dose monitoring electronic solution allow us reeucing the variability on the dose in non-focused pediatric departments anddeterminate root causes to fix them

ParticipantsYasuyuki Ueda, Fukuoka, Japan (Presenter) Nothing to DiscloseJunji Morishita, PhD, Fukuoka, Japan (Abstract Co-Author) Nothing to DiscloseShohei Kudomi, Ube, Japan (Abstract Co-Author) Nothing to DiscloseKatsuhiko Ueda, BS, Ube, Japan (Abstract Co-Author) Nothing to Disclose

PURPOSE

Patient misidentification error management is one of the important factors of patient safety. We studied the use of magneticresonance (MR) images for the purpose of biometric patient identity verification, and show the accuracy of verification performancefor clinical use.


Anatomy-related multi-planar reconstruction (MPR) images, including posterior surface of brainstem and the internal auditory canal(IAC), generated from one three-dimensional fast scout scan of each MR examination were used as biological-fingerprint images inthis study. We calculated a correlation value as a similarity score between current and prior biological-fingerprint images. Thisprocedure consists of three major steps, i.e., biological feature extraction, normalization, and calculation of correlation value. Inorder to evaluate the verification performance, we calculated a false rejection rate (FRR), a false acceptance rate (FAR) and ahalf-total error rate (HTER) by the discriminant analysis utilizing the squared Mahalanobis distance to declare the patient as genuineor an impostor. Moreover, to evaluate overall performance deliverance from a receiver operating characteristic (ROC) curve, thearea under the ROC curve (AUC), and the equal error rate (EER) were calculated.

RESULTS

The database of this study consisted of 730 temporal pairs of MR examination of the brain. Many patients of this study have thefollowing disorders: brain tumor and cerebrovascular angiopathy, and 168 patients have undergone surgical operation of the brainbefore the current examination. Our results indicated a high performance in verifying patients. Our method gave an HTER of 1.59%with an FAR of 0.023% (62/266,085), and an FRR of 3.15% (23/730). The AUC and EER were achieved at 0.998 and 1.37%,respectively.

CONCLUSION

Our method makes it possible to verify the identity of the patient only using some existing medical images without the addition ofincidental equipment. We expect our method to be a key solution to patient misidentification problems.

SSQ11-07 CT Dose Monitoring and Management System Based on Open-source Software Resources and In-House Development


SSQ11-08 Implementation of a Virtual 'Learning from Discrepancy' Meeting: A Method to Improve RadiologistAttendance and Facilitate Shared Learning from Radiological Error



Our method is useful when we have no other way of confirming whether the registered patient information is correct or not and willcontribute to patient misidentification error management caused by human errors.

ParticipantsDa Zhang, PhD, Boston, MA (Presenter) Nothing to DiscloseLarry Barbaras, Boston, MA (Abstract Co-Author) Nothing to DiscloseMatthew R. Palmer, PhD, Boston, MA (Abstract Co-Author) Nothing to Disclose

PURPOSE

The monitoring and management of radiation dose have become crucial requirements of modern radiology departments. Powerfulopen-source DICOM utilities could facilitate the implementation of professional-grade systems for collecting CT radiation dose data.However, the heterogeneity of dose data and inconsistent implementations of the DICOM SR standard among different CT modelsand vendors require additional customization and programming. We present the development, unique features, and clinicalapplicability of a CT dose tracking system based on freely-available software resources.


Radiation dose structured reports (RDSR) are auto-transmitted from the CT scanners to a Conquest DICOM server. The serverspawns two external processes: 1) 'dcm2xml' (from DCMTK) translates RDSR into XML; 2) a PowerShell script mines the XML dataand populates database tables.Dose dashboards on the server provide query and display functionality for individual CT exams, whilea data dump service provides massive output of dose records for periodic dose analysis and protocol management. Also, a webservice that receives real-time queries from the dictation system returns customized dose strings for automatic inclusion in theradiologic reports.For protocol review, dose entries in the dumped data are cleaned and validated. Heterogeneous protocolidentifiers are normalized and re-mapped to core protocol names, using a regular expression based method. Similar protocol namesare grouped together for per-scanner analysis and cross-scanner comparison. The core protocols that comprise the majority ofexams were identified, and summary data were prepared for visual analysis.

RESULTS

Over 5000 CT dose records per month have been collected from ten CT scanners (of 7 models and 3 vendors) distributed in threepractice sites. Non-trivial inconsistencies in the adoption of RDSR capabilities, especially in the handling of protocol names, wereobserved. Comparison of dose performance across scanners and against national data was used to trigger root-cause analysis andprotocol review.

CONCLUSION

Using open-source software resources and in-house expertise, a highly functional and customizable dose monitoring andmanagement system can be developed with limited expense and effort.


The developed dose tracking and reporting system could greatly facilitate the tasks of CT dose monitoring and management.

ParticipantsAnoma Lalani Carlton Jones, MBBS, FRCR, London, United Kingdom (Presenter) Nothing to DiscloseMary E. Roddie, MD, London, United Kingdom (Abstract Co-Author) Nothing to Disclose

PURPOSE

To assess the effect on radiologist participation in learning from discrepancy meetings (LDMs) in a large radiology departmentspread across three hospital sites by establishing virtual LDMs using OsiriX (Pixmeo).


Submitted radiological discrepancy cases were added to an OsiriX database after anonymisation with clinical information available atthe time and any relevant previous imaging. Prepared cases were loaded onto iMacs in the radiology reporting rooms on each site.For each virtual LDM radiologists were given a 3-week period to review cases either on their own or in groups and send theirfeedback to the LDM convenor. The learning points and consensus feedback were attached to each case before it was added to apermanent LDM library on the iMacs. Attendance was recorded and compared with that from the previous 4 years of conventionalmeetings. We obtained radiologist feedback comparing the two types of LDM using an anonymous online questionnaire sent outafter the first year of virtual LDMs.

RESULTS

Numbers of radiologists attending increased significantly from a mean of 12.5 ± 3.1 for the conventional LDM to 27.3 ± 6.2 for thevirtual LDM (p < 0.0001) and the percentage of radiologists achieving the UK standard of participation in at least 50% of LDMs peryear (the UK standard) rose from an average of 18% to 68%. The number of cases submitted per meeting rose significantly from anaverage of 11.1 ± 2.9 for conventional LDMs to 15.2 ± 6.2 for virtual LDMs (p < 0.02). Analysis of 30 returned questionnairesshowed that radiologists welcomed being able to review cases at a time and place of their choosing and at their own pace. Theyreported that were able to give more honest feedback in the absence of peer pressure. Many felt that the LDM library was a usefuleducational resource and had changed their clinical practice by highlighting frequently occurring errors.

CONCLUSION

SSQ11-09 Does Dose Awareness Increase after Implementation of a Dose Monitoring Software in ComputedTomography

Thursday, Dec. 3 11:50AM - 12:00PM Location: S403A

Replacement of conventional LDMs rotating between hospital sites in a large radiology department by virtual LDMs improvedradiologist participation in the process of group learning from radiological discrepancy and increased the number of submitted cases.


Introduction of a virtual 'learning from discrepancy' meeting (LDM) and an LDM library can increase radiologist participation in theprocess of learning from discrepancy and increase the number of cases submitted.

ParticipantsChristina Heilmaier, MD, Zurich, Switzerland (Presenter) Nothing to DiscloseNiklaus Zuber, Zurich, Switzerland (Abstract Co-Author) Nothing to DiscloseDominik Weishaupt, MD, Zurich, Switzerland (Abstract Co-Author) Nothing to Disclose

PURPOSE

Dose monitoring becomes more and more important and is an important part of quality control. We wanted to examine whether doseawareness of medical staff increased after a dose monitoring software was installed and implemented in clinical routine.


Dose data of two computed tomography scanners was collected from April 2014 to February 2015. We used a dose managementsoftware to separately analyze data from April to June 2014 (period 1) and July 2014 to February 2015 (period 2). Starting July2014 radiographers were instructed look for and answer alarms ('alerts') when dose exceeded predefined thresholds. Chi-squaretests were applied to check for statistical significant changes in number and reasons for alerts between both periods. Thresholdswere set as 75th-percentile of the distribution of dose length product (DLP, Gy*cm).

RESULTS

A total of 13,217 scans were conducted (period 1, n=4,943; period 2, n=8883) and dose data was successfully transferred to thesoftware in all cases. A total of 609 alerts occurred (period 1, n=293; period 2, n=316), mean alert quota 5%. Comparison of bothperiods showed a significant decrease of mean alert quota in period 2 (4%; period 1, 6%; p<0.001). Decline was mainly caused by areduced number of notifications due to patient off-centering (period 1, n=129; period 2, n=77; p<0.001), which means patient wasnot positioned properly in the isocenter of the scanner. Relative number of high body weight alerts (BMI≥25 kg/m2) grew in period 2(51%, n=160; period 1, 36%. n=106), but difference was not statistical significant (p=0.159). All other alert causes werecomparable in both periods (p>0.05): scan repetition due to severe motion artifacts (period 1, n=32, 11%; period 1, n=36, 11%),osteosynthesis material (OSM) in scanning area and leading to dose up-regulation (period 1, n=24, 8%; period 2, n=28, 9%) andothers such as imaging on spine-board (period 1, n=3, 1%; period 2, n=15, 5%).

CONCLUSION

A dose monitoring software can be successfully implemented in clinical routine and increases dose awareness in medical staff,thereby leading to a reduction of the number of dose alerts due to human error.


Implementation of a dose monitoring software in clinical routine can be successfully accomplished and is an important tool forincreasing dose awareness in medical staff, thereby improving quality assurance and patient safety.

SSQ19-01 Atypical Head CT Artifact-Potential for Misdiagnosis

Thursday, Dec. 3 10:30AM - 10:40AM Location: S403B

SSQ19-02 Estimation of Bias Corrections in Observer Model Performance Metrics for Accurate Comparisons ofCT Image Quality


SSQ19

Physics (CT VII-Image Quality I)

Thursday, Dec. 3 10:30AM - 12:00PM Location: S403B

CT PH SQ



ParticipantsKatsuyuki Taguchi, PhD, Baltimore, MD (Moderator) Research Grant, Siemens AGTinsu Pan, PhD, Houston, TX (Moderator) Nothing to Disclose

Sub-Events

ParticipantsRaja Subramaniam, PhD, Brooklyn, NY (Abstract Co-Author) Nothing to DiscloseJo-Ann Provencher, MS, New York, NY (Presenter) Nothing to DiscloseIdoia Corcuera-Solano, MD, New York, NY (Abstract Co-Author) Nothing to DiscloseLuke C. Gerke, MD, New York, NY (Abstract Co-Author) Nothing to DiscloseSerge Sicular, MD, New York, NY (Abstract Co-Author) Nothing to DiscloseLawrence N. Tanenbaum, MD, New York, NY (Abstract Co-Author) Speaker, General Electric Compnny; Speaker, Bracco Group;Speaker, Bayer AG; Speaker, Siemens AG; Speaker, Guerbet SABradley N. Delman, MD, New York, NY (Abstract Co-Author) Nothing to Disclose

Background

The accurate diagnostic of strokes is crucial as misdiagnosis can lead to administration of unnecessary treatment, patient stressand pointless follow up scans. The timely identification of artifacts is crucial to the limitation of misdiagnosis. We reported a rareartifact on head CT that led to 6 misdiagnosis before it was identified. Our purpose it to present this artifact manifestation to allowearly detection to avoid potential clinical misdiagnosis.

Evaluation

This artifact occurred on a GE LightSpeed VCT XT CT and exhibited subtle areas of decreased attenuation mostly involving the leftfrontal cortex and periventricular white matter, the imaging appearance suggestive of ischemia/infarct. In all cases, a 2nd CT or abrain MR scan was performed, refuting the presence of acute ischemia. The possibility of the artifact was pointed out after severalscans provided similar diagnosis on asymptomatic patients with unremarkable follow up CT or MR imaging. The daily QA phantomwas scanned and analyzed, revealing the presence of low attenuation streaks, mostly located in the upper right quadrant.

Discussion

The artifact was caused by air leak into the oil used for cooling the X-ray tube. GE VCT has the heat exchanger located outsidethe tube housing. Oil is circulated between housing and the heat exchanger via a hose, attached using 'quick disconnect'connector. This mechanical part, over periods of use, can allow air to leak in. A leaked air bubble located in the tube port created aregion of low attenuation, which was translated as dark streaks in our images. The problem was corrected after fresh oil was cycledthrough the cooling system

Conclusion

Our aim was to educate on the possibility and visual appearance of this artifact, its cause, and corrective actions necessary torectify the situation. This is an artifact that seems germane to CT units that have the heat exchanger isolated from the X-raytube. Prompt discovery of this artifact would prevent unnecessary patient anxiety, administration of costly and time consumingadditional scans (and associated increased radiation dose) and administration of unnecessary and potentially harmful treatments.

ParticipantsChristopher P. Favazza, PhD, Rochester, MN (Presenter) Nothing to DiscloseLifeng Yu, PhD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseShuai Leng, PhD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseKenneth A. Fetterly, PhD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseCynthia H. McCollough, PhD, Rochester, MN (Abstract Co-Author) Research Grant, Siemens AG

PURPOSE

To accommodate the increasing adoption of iterative image reconstruction techniques, observer models have been proposed toevaluate CT image quality across spectra of scanners, protocols, tasks, and reconstruction methods. A major limitation of suchmodels is the requirement of a large number of images (N) to train the model, as bias in performance increases with reducing N. Theaim of this study was to evaluate a method to correct for finite sampling bias in model performance for an object detection task inreal CT images and to investigate observer model performance bias as a function of both dose and N.


A previously validated channelized Hotelling observer (CHO) model was employed to evaluate the detectability of a 3 mm diameter

SSQ19-03 A Task-Based kV-mAs Optimization Framework for Both Linear and Nonlinear CT Systems


A previously validated channelized Hotelling observer (CHO) model was employed to evaluate the detectability of a 3 mm diametercircular object. The object was submerged in a 35x 25 cm2 iodine-doped water filled phantom, yielding -15 HU object contrast. Thephantom was scanned with 3 different dose levels (quantified by CTDIvol): 3.6, 7.2, and 21.8 mGy. For each dose level, thephantom was scanned 100 times with and without the object present. A bias-corrected CHO detectability index (bc-DI) wasderived from DIs calculated with varied numbers of training images (N). Specifically, bc-DI values were determined from interceptvalues of linear fits of DI versus 1/N for all dose levels. Additionally, bc-DI values were derived from limited datasets: 70, 80, and 90total images and compared with bc-DI values obtained from the full 100 image datasets.

RESULTS

Estimates of bc-DI values revealed variable bias in DI as a function of dose. DI values calculated for images acquired with higherdose levels yielded greater absolute bias as compared to the DI values calculated from image acquired with lower dose levels. Forall dose levels, estimates of bc-DI values derived from reduced datasets were consistent; percent deviations from the value derivedfrom N=100 were ≤ 7%.

CONCLUSION

The use of a finite number of training images leads to bias in the CHO's performance that varies with dose and number of trainingimages. Through the methodology employed here, it is possible to estimate reliable bc-DI values with reduced number of trainingimages.


Observer models are being widely investigated to evaluate and compare CT image quality. Variability in model performance biasshould be well-understood for accurate image quality comparisons.

ParticipantsDaniel Gomez-Cardona, Madison, WI (Presenter) Nothing to DiscloseKe Li, PhD, Madison, WI (Abstract Co-Author) Nothing to DiscloseMeghan G. Lubner, MD, Madison, WI (Abstract Co-Author) Grant, General Electric Company; Grant, NeuWave Medical, Inc; Grant,Koninklijke Philips NVPerry J. Pickhardt, MD, Madison, WI (Abstract Co-Author) Co-founder, VirtuoCTC, LLC; Stockholder, Cellectar Biosciences, Inc;Research Consultant, Bracco Group; Research Consultant, KIT ; Research Grant, Koninklijke Philips NVGuang-Hong Chen, PhD, Madison, WI (Abstract Co-Author) Research funded, General Electric Company; Research funded, SiemensAG

PURPOSE

Zero-frequency metrics such as the contrast-to-noise ratio (CNR) are commonly used for the optimal selection of tube voltage (kV)and tube current-rotation time product (mAs) in CT. However, these metrics are invalid for nonlinear CT systems such as thoseusing model based iterative reconstruction (MBIR) algorithms. This study reports a new task-based framework to optimize theselection of kV and mAs for both linear and nonlinear CT systems.


Using the frequency-dependent modern signal detection theory, kV/mAs optimization was formulated as a constrained minimizationproblem: choose the kV/mAs that minimizes radiation dose while maintaining the clinically prescribed detection performance. Toexperimentally solve this constrained optimization problem, exhaustive measurements of the detectability index (d') for a hepaticlesion detection task were performed with a fixed rotation time at 15 different mA levels (25 to 700) and at 4 kV levels (80 to 140)in an anthropomorphic phantom; these values were used to generate an iso-detectability contour map. Similarly, an iso-dosecontour map was generated using the measured doses for each kV/mAs combination and was then overlaid with the iso-detectability map. Thus, for a prescribed detectability level (d'p), the optimal kV-mA combination could be determined as theintersection between the d'p contour and the minimum dose contour. These results were then validated with an in vivo animalstudy.

RESULTS

For a prescribed detectability level of d'=16, the kV-mAs combinations (followed by CTDIvol dose levels (mGy) in parentheses) onthe measured iso-detectability contour of MBIR were 80-150 (3.8), 100-140 (6.6), 120-150 (11.3), and 140-160 (17.2). Thus, theoptimal kV-mA was 80-150 (3.8) for MBIR; in comparison, the optimal kV-mA for FBP was 100-500 (23.7 mGy). These resultsprovided image quality and dose reduction factors in our in vivo study and were consistent with the phantom results.

CONCLUSION

A new method to optimize kV and mA selection in CT has been developed in this work that is applicable to both linear and nonlinearCT systems such as those equipped with MBIR. The maximum dose reduction can be potentially achieved by combining MBIR withoptimal kV-mA selections.


This framework can help with the optimization of kV and mAs selection, the most important measure in daily CT exams to reduceunnecessary radiation exposures to the patients.

Honored Educators


Meghan G. Lubner, MD - 2014 Honored EducatorMeghan G. Lubner, MD - 2015 Honored Educator

SSQ19-04 Inserting Realistic Lesions into CT Images: A Valuable Tool for Optimization of CT Image Quality andRadiation Dose


SSQ19-05 Accuracy of Lung Nodule Volume Measurement in Lung-cancer Screening CT at Radiation Dose LevelEquivalent to Chest X-rays


Perry J. Pickhardt, MD - 2014 Honored Educator


ParticipantsBaiyu Chen, Rochester, MN (Presenter) Nothing to DiscloseChi Ma, PhD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseShuai Leng, PhD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseLifeng Yu, PhD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseJeff L. Fidler, MD, Rochester, MN (Abstract Co-Author) Research Grant, Beekley CorporationShannon P. Sheedy, MD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseCynthia H. McCollough, PhD, Rochester, MN (Abstract Co-Author) Research Grant, Siemens AGJoel G. Fletcher, MD, Rochester, MN (Abstract Co-Author) Grant, Siemens AG; ;

PURPOSE

To optimize CT image quality and radiation dose for lesion detection tasks, patient images with lesions of known characteristics areneeded. Although these images can be collected via clinical trials, the process is expensive and time consuming. This study aims tovalidate a recently developed lesion insertion technique, which allows lesions of known characteristics to be inserted into patientCT images for evaluation of detection performance.


Lesions were segmented from patient CT images, forward projected, and inserted into patient CT projections using a recentlydeveloped computer program. The modified patient projections were formatted to match that of commercial CT raw data andreconstructed on scanners to yield images with inserted lesions. To validate the realism of the inserted lesions, 54 liver lesions weresegmented from patient images and inserted back into the same patients at new locations. The 54 inserted lesions, together withthe 54 real lesions in their original locations, were examined interactively in consensus by two experienced radiologists. First, the108 lesions were viewed in a randomized and blinded fashion. Each lesion was scored from 1 to 10 (1=absolutely inserted to10=absolutely realistic). Second, the 108 lesions were viewed in pairs (real vs inserted) in a blinded fashion with radiologistsinstructed to select the inserted lesion and provide a confidence level (1=no confidence in determination to 5=completely certain).

RESULTS

For the lesions viewed randomly, 35 inserted and 39 real lesions were scored ≥7, whereas 6 inserted and 2 real lesions were scored≤3. The medians and interquartile ranges of the scores were the same for real and inserted lesions (median 8; interquartile range 6-8). The p-value of a paired t-test was 0.3. For the lesions viewed in pairs, the inserted lesions were incorrectly identified in 27/54pairs (50%) when not considering the confidence level, or 5/11 pairs (45%) when radiologists were confident they had correctlyidentified the inserted lesion (confidence level ≥4).

CONCLUSION

A lesion insertion technique has been developed and validated, which can be used for optimization of image quality and radiationdose.


The successful insertion of lesions into patient images allows quick evaluation of new techniques such as iterative reconstruction,such that patient image quality and radiation dose can be optimized.

ParticipantsChi Ma, PhD, Rochester, MN (Presenter) Nothing to DiscloseBrian J. Bartholmai, MD, Rochester, MN (Abstract Co-Author) License agreement, ImBio, LLC; Scientific Advisor, ImBio, LLC;Scientific Advisor, Bristol-Myers Squibb CompanyLifeng Yu, PhD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseJoel G. Fletcher, MD, Rochester, MN (Abstract Co-Author) Grant, Siemens AG; ; Shuai Leng, PhD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseCynthia H. McCollough, PhD, Rochester, MN (Abstract Co-Author) Research Grant, Siemens AG

PURPOSE

Use of an x-ray beam with added tin filter (100Sn) may allow lung cancer screening CT to be performed at a dose level approachingthat in a chest x-ray. The purpose of this study was to evaluate the accuracy of lung nodule volume measurements at such a lowdose level.


An anthropomorphic chest phantom (Lungman, Kyoto Kagaku) was used to simulate an adult patient. Total of eight sphericalnodules at two contrasts (100 and -800 HU) and four sizes (5, 8, 10 and 12 mm diameter) were attached to simulated pulmonaryvessels. The nodules were located at similar distance from the isocenter to reduce the impact of non-uniform spatial resolutionacross the field of view. The phantom was scanned on a 192-slice CT scanner (Force, Siemens) using 100Sn kV at 4 dose levels(0.1, 0.15, 0.4, and 1.5 mGy). The two lowest dose levels at 100Sn corresponded to effective doses similar to a typical 2-viewchest x-ray. The phantom was also scanned using 120 kV at 3 dose levels (0.4, 1.3, 6.9 mGy). Images were reconstructed using anIR method (ADMIRE, Siemens) with a kernel of Bv49-2. An experienced radiologist selected a seed point for automated nodulesegmentation and volume measurement for all 8 nodules on each of the 7 datasets using automated segmentation tool (LungSAT,

SSQ19-06 Method for Producing Surrogate Soft-tissue Materials for X-ray and CT Phantom Imaging Studies


SSQ19-07 Initial Application of Attenuation-based kV Select Technique (kV Assist) in Lumber CT Examination


TeraRecon iNtuition version 4.4.11.164.7713). The accuracy of the volume measurement was quantified as the percent differencebetween the estimated volume and the nominal volume provided by the phantom manufacturer.

RESULTS

Percent errors remained relatively stable for high-contrast nodules (100HU) for both 120 kV and 100Sn at all dose levels. At thelowest dose level at 100Sn, the percent errors (16%, -16%, -13%, -9% for 5, 8, 10, and 12 mm nodules) were close to that at thehighest dose level (18%, -15%, -9%, -8%). Accuracy degraded with the lower contrast nodules at -800 HU. The percent errorswere -67%, -67%, -96%, -98% for the four sizes at the lowest dose level compared to 113%, 20%, 80%, 59% at the highest doselevel at 100Sn.

CONCLUSION

Accuracy of automated volume measurement was maintained on high-contrast nodules at a dose level equivalent to a chest x-rayusing the added tin filter in lung cancer screening CT. Accuracy may degrade for low-contrast nodules due to increased noise.


At the dose levels used for lung cancer screening, the accuracy of automated measurements of lung volume is an importantparameter to assess.

ParticipantsPaul Fitzgerald, Niskayuna, NY (Presenter) Employee, General Electric CompanyRobert E. Colborn, PhD, Niskayuna, NY (Abstract Co-Author) Employee, General Electric CompanyPeter Edic, Niskayuna, NY (Abstract Co-Author) Employee, General Electric CompanyJack Lambert, PhD, San Francisco, CA (Abstract Co-Author) Nothing to DiscloseBenjamin M. Yeh, MD, San Francisco, CA (Abstract Co-Author) Research Grant, General Electric Company; Author with royalties,Oxford University Press; Shareholder, Nextrast, Inc; Peter J. Bonitatibus JR, PhD, Niskayuna, NY (Abstract Co-Author) Employee, General Electric Company

PURPOSE

Phantom studies are used to develop and validate CT imaging performance; however, it has been difficult to obtain materials thatclosely approximate the energy-dependent X-ray attenuation of human soft tissues. We sought to develop a simple method forproducing soft-tissue equivalent materials that can be easily modified with low concentrations of contrast media in order toaccurately emulate perfused internal organs.


We evaluated hypothetical mixtures of water, glycerol, butanol, methanol, NaCl, and KNO3 which were intended to emulate humanadipose, blood, brain, kidney, liver, muscle, pancreas, and skin. We compared the hypothetical densities and simulated X-rayattenuation coefficients of the proposed materials with those of human tissue elemental composition as specified in ICRU Report 46.We then physically formulated the proposed liquid surrogates for adipose, liver, and pancreas, and measured the HU of thesematerials when placed within a medium-sized anthropomorphic phantom in a 64-slice clinical CT scanner operating at 80, 100, 120,and 140 kVp.

RESULTS

The predicted densities and simulated X-ray attenuation coefficients of our proposed formulations agreed with those of ICRU tissuecompositions within <1%. For example, the densities (g/mL) of our hypothetical materials (and ICRU's) were: adipose 0.947 (0.95),pancreas 1.041 (1.04), and liver 1.059 (1.06); the monochromatic energy HU at 60 keV of our hypothetical materials (and ICRU's)were: adipose -88.3 (-88.7), pancreas 31.1 (31.3), and liver 55.7 (55.2). The densities of our physically formulated materials were:adipose 0.947, pancreas 1.061, and liver 1.074. Our empirical HU measurements at 80 kVp were: adipose -85, pancreas 48, andliver 67; at 120 kVp these were: adipose -66, pancreas 51, and liver 65.

CONCLUSION

Our method for formulation of tissue surrogates allowed rapid production of materials with HU values at CT that closely matched thetarget tissues' expected HU values and HU trends with kVp. Further study is warranted, such as comparison with commercialtissue-equivalent plastics, and introduction of contrast agents. Validation may potentially accelerate development and testing ofadvanced CT imaging technologies.


Our tissue emulation method may accelerate development of optimized CT imaging technologies such as quantitative spectralimaging and for detection of subtle characteristics in diseased soft tissues.

ParticipantsYeda Wan SR, Tianjin, China (Abstract Co-Author) Nothing to DiscloseFei Fu, Tianjin, China (Presenter) Nothing to DiscloseYue Zhang, Tianjin, China (Abstract Co-Author) Nothing to DiscloseAnwei He, Tianjin, China (Abstract Co-Author) Nothing to DiscloseBaojiu Li, Tianjin, China (Abstract Co-Author) Nothing to DiscloseJiyang Zhang, Tianjin, China (Abstract Co-Author) Nothing to DiscloseXin Deng, MD, Tianjin, China (Abstract Co-Author) Nothing to DiscloseJian Li, Tianjin, China (Abstract Co-Author) Nothing to Disclose

PURPOSE

SSQ19-08 Detectability of Low-Contrast, Low-Attenuation (LCLA) Liver Lesions on CT with FBP and ADMIRE:Assessment using a Channelized Hotelling Model Observer


SSQ19-09 Reexamination of the Meaning of Effective Energy in CT

Thursday, Dec. 3 11:50AM - 12:00PM Location: S403B

As a newly introduced technique, tube kilovolt (kV) assist based on the attenuation profile of the scout scan provides automatedkV and mA selection. Aim of this study was to assess radiation dose reduction and image quality for lumber CT examination with kVAssist technique, compared to a standard 120 kV protocol.


With institutional review board approval, 60 patients(male,30-40y)underwent lumber CT scan were randomly separated into twogroups: conventional 120 kV group with tube current of 230mA (n=30) and kV assist group (n=30). The slice thickness was1.25mm. Image noise and CT value of the L3 vertebral body center level and erector apinae were measured. Signal-to-noise ratio(SNR) and contrast-to-noise ratio (CNR) for vertebral body were calculated, according the formulas: SNR=CTver/SD and CNR=(CTver-CTmus)/SD. The volumetric CT dose index (CTDIvol) was recorded. Subjective image quality was evaluated by tworadiologists with a 5-grade scale. Data was compared with student T-test and rank sum test.

RESULTS

With kV Assist, the percentage of patients scanned using 80 kV, 100 kV and 120 kV was 80.2%, 16.7 % and 3.1 %, respectively.140 kV was not selected in this study. Compared with the conventional 120 kV protocol, kV Assist allowed for an overall averagedecrease of 45 % in CTDIvol (8.73±0.28 mGy vs 15.77±0.10 mGy, p<0.05). The SNR have no statistical difference between kVassist group and conventional 120 kV group (2.54±0.67 vs 2.95±0.60, p>0.05). The CNR and image quality score of kV assist groupwere higher than those of conventional 120 kV group (CNR,2.23±0.92 vs 1.75±0.60; score, 4.40±0.52 vs 3.60±0.70, both p<0.05).

CONCLUSION

In lumber CT examination, application of attenuation-based kV Assist technique enables an average of 45% dose reduction inenhanced, and provide better image quality.


As a newly introduced technique, application of kV assist technique enables an average of 45% dose reduction in enhanced inlumber CT examination, and provide better image quality.

ParticipantsArjun Maniyedath, MS, Shaker Heights, OH (Presenter) Employee, Plexar Associates, IncFrank Dong, PhD, Solon, OH (Abstract Co-Author) Equipment support, Siemens AG Software support, Siemens AGAndrew Primak, PhD, Malvern, PA (Abstract Co-Author) Employee, Siemens AGWadih Karim, RT, Cleveland, OH (Abstract Co-Author) Nothing to DiscloseAjit H. Goenka, MD, Cleveland, OH (Abstract Co-Author) Institutional Research Grant, Siemens AGMark E. Baker, MD, Cleveland, OH (Abstract Co-Author) Research Consultant, Bracco Group; Researcher, Siemens AG; Researchsupport, Siemens AGBrian R. Herts, MD, Cleveland, OH (Abstract Co-Author) Research Grant, Siemens AG

PURPOSE

To assess differences in detectability of LCLA liver lesions with filtered back-projection (FBP) and Advanced Modeled IterativeReconstruction (ADMIRE) in a semi-anthropomorphic phantom using a model observer.


A custom-designed abdominal phantom with low attenuation (90 HU) liver insert (10-cm length x 10-cm diameter) containing 3copies each of 4 unique spherical lesions (15-mm x 84 HU, 10 mm x 78 HU, 10 mm x 72 HU, and 5 mm x 66 HU) was scanned on aSiemens Somatom Force CT scanner at 6 exposure settings: 200, 160, 120, 80, 40 and 20 effective mAs. At each exposure level,liver insert was rotated by 90 degrees and 25 scans were performed per rotation to allow assessment of lesion-present/absent pairsfrom the same [X,Y,Z] location in the phantom (for a total of 100 scans at each exposure). Images were reconstructed with bothFBP and ADMIRE (strengths 3 and 5). A Channelized Hotelling Model Observer with 40 Gabor channels was used to evaluate pairs of100 images, and the detectability signal-to-noise ratio (d') values were computed.

RESULTS

The CHMO showed progressively higher d' values for greater ADMIRE strengths compared to FBP at all exposure levels. ADMIREshowed largest improvement of 26% in d' for the largest lesion (15 mm x 6HU). The low contrast detectability (LCD) improvementwas in the 3-18% range for the 10mm x 18HU and 10mm x 12 HU lesions, across the six dose levels. The three different 5mm x 24HU lesions had inconsistent and inconclusive results.

CONCLUSION

Our CHMO analysis showed improved LCD performance of ADMIRE with respect to FBP at all exposure levels for all 10mm and 15mmlesions.


Objective assessment of low contrast detectability performance in a controlled environment is important in order to determine thedose reduction potential of novel iterative reconstruction methods without loss of diagnostic accuracy in detection of low-contrastliver lesions.

ParticipantsAustin Healy, MS, Greenwich, NY (Presenter) Employee, The Phantom LaboratoryDavid J. Goodenough, PhD, Myersville, MD (Abstract Co-Author) Director, The Institute for Radiological Image Sciences, Inc;

Consultant, The Phantom Laboratory; Consultant, Live Radiology, LLC; Consultant, Image Owl, IncHildur Olafsdottir, Salem, NY (Abstract Co-Author) Research funded, Image Owl, IncJesper Fredriksson, Salem, NY (Abstract Co-Author) Employee, Raforninn ehf Asbjorn Kristbjornsson, Reykjavik, Iceland (Abstract Co-Author) Research funded, Image Owl, Inc

PURPOSE

This paper will reexamine the concept and interpretation of the use of "effective energy" in CT. We identify caveats ininterpretation compared to the historical use of the term in Radiation Physics, particularly as it pertains to Radiological Imaging. Inparticular, we examine how issues related to reconstruction of data acquired at the detector, over many projection angles andvariable object thickness and shape can lead to significant differences compared to attenuation data acquired using attenuatingsheets between the source and the detector. We address the issue of how the resulting CT numbers are related to the differentialattenuation of a material compared to water, considering various corrections for beam hardening, scatter, beam shaping filters andall aspects of possible manipulation following the original reconstruction.


The Catphan® (The Phantom Laboratory, Salem, NY), designed to offer test objects of known (or calculable) density and x-rayattenuation properties, was scanned using different scanners and protocols. The resulting CT numbers are plotted against a seriesof attenuation coefficients that result from assuming different effective energies of the CT beam. The best fit to the measureddata compared to the energy dependent coefficients is obtained. Contrast scale and noise, functions of the choice of effectiveenergy and required by the FDA, are calculated.

RESULTS

CT scans of known materials at various kVp's, filtration, and scanner design are used to show the sometimes confusing results ofeffective energy. In particular, wide x-ray beams such as used in large multislice scanners and volume scanners are shown to leadto ambiguous and in some cases clearly flawed results. Although the term is shown to be somewhat useful in a constancy sense, itsuse is shown as challenging in a Radiation Physics sense.

CONCLUSION

The challenges to measurement and interpretation of "effective energy" in CT are shown. It is suggested that a new term might beused to reinforce the caveats in the measurement in this term. This term could be as simple as Eeff (CT) but any other term tomove away from the classical meaning of effective energy and related radiation measurements might be useful.


Since the FDA requires a measure of the Contrast Scale in evaluating CT performance, it is important to understand the concept of"effective energy" may be misleading to the radiologist and the physicist.

SSQ21-01 Simulation Based Training Improves Resident Skill in Ultrasound-Guided Biopsy

Thursday, Dec. 3 10:30AM - 10:40AM Location: E352

SSQ21-02 Ultrasound Guided Foreign Body Removal (USFBR): Simulation Training and Clinical ImplementationOutcomes


SSQ21

Vascular/Interventional (Improving Education and Outcomes in Interventional Radiology)

Thursday, Dec. 3 10:30AM - 12:00PM Location: E352

ED SQ IR

AMA PRA Category 1 Credits ™: 1.50ARRT Category A+ Credit: 1.00

ParticipantsKelvin K. Hong, MD, Baltimore, MD (Moderator) Scientific Advisory Board, Boston Scientific Corporation; Steven M. Zangan, MD, Chicago, IL (Moderator) Nothing to Disclose

Sub-Events

ParticipantsNicholas L. Fulton, MD, Cleveland, OH (Presenter) Nothing to DiscloseJi Y. Buethe, MD, Cleveland, OH (Abstract Co-Author) Research Grant, Galil Medical LtdJayakrishna Gollamudi, MD, Cincinnati, OH (Abstract Co-Author) Nothing to DiscloseMark R. Robbin, MD, Cleveland Hts, OH (Abstract Co-Author) Nothing to Disclose

PURPOSE

The purpose of this study was to determine whether ultrasound-guided biopsy simulation training using a high fidelity abdominalimaging phantom can improve the radiology residents' overall technical competence in ultrasound guided biopsy.


This is an IRB approved prospective study. Forty radiology residents from a single institution were enrolled and randomized intotraining (TG) or control (CG) groups. Each resident performed an ultrasound-guided biopsy on a high-fidelity abdominal imagingphantom using a 22-gauge needle. Prior experience in ultrasound guided biopsies (number of months and procedures performed),total procedure time, number of skin punctures, and number of needle adjustments were obtained. Each procedure was evaluatedby a blinded board certified radiologist using a 5 point Likert scale technical competence score. The TG cohort received anadditional 30 minute simulation training session with an experienced senior resident. The CG cohort received no additional training.Each resident underwent a second procedure and the same metrics were measured. Statistical analysis was performed usingindependent t tests.

RESULTS

There were no statistically significant differences between the TG and CG with regards to prior ultrasound-guided biopsyexperience. No significant differences between the two cohorts were present in the initial procedure. After the training session, thetraining cohort demonstrated a statistically significant improvement in overall procedure time (92 seconds less), number of skinpunctures (0.8 less), number of needle adjustments (1.4 less), and subjective performance on a 5-point Likert scale (1.1 more) asdetermined by a blinded grader. The CG did not demonstrate a statistically significant difference in any of the measured metricsbetween the two procedures.

CONCLUSION

The use of an abdominal imaging phantom for training radiology residents in ultrasound-guided biopsy performance can improveprocedural skills including shorter procedure times, less skin punctures, less needle movements and improved subjectiveperformance by a blinded grader. Additional randomized controlled trials will be necessary to determine the external validity of thestudy in regards to improved patient outcomes and IR-department turnaround time.


This study demonstrates the efficacy of simulation training on improving resident performance in ultrasound-guided biopsy.

ParticipantsVeronica J. Rooks, MD, Honolulu, HI (Abstract Co-Author) Nothing to DiscloseJefferey M. Meadows, Tripler AMC, HI (Presenter) Nothing to DiscloseChristian L. Carlson, MD, MS, Cibolo, TX (Abstract Co-Author) Nothing to DiscloseMichael V. Krasnokutsky, MD, Olympia, WA (Abstract Co-Author) Nothing to DiscloseFrank E. Mullens, MD, MPH, Bethesda, MD (Abstract Co-Author) Nothing to DiscloseBeth M. Haeuptle, BS,MA, Columbus, OH (Abstract Co-Author) Nothing to DiscloseMichael Lustik, Tripler AMC, HI (Abstract Co-Author) Nothing to DiscloseJames W. Murakami, MD, Columbus, OH (Abstract Co-Author) Nothing to DiscloseWilliam E. Shiels II, DO, Columbus, OH (Abstract Co-Author) President, Mauka Medical Corporation; Royalties, Mauka MedicalCorporation; Patent holder, Mauka Medical Corporation

PURPOSE

USFBR can be taught to radiologists in a stepwise approach to generate competency, and radiologists can apply the technique inthe patient setting to remove foreign bodies.

SSQ21-03 Evaluation of a Gelatin-Based Phantom Model System for Training of CT-Guided Drain Placement


SSQ21-04 Use of an Electromagnetic Navigation System on a Phantom as a Teaching ModalityTo ImproveTraining for CT-Guided Procedures



USFBR was taught to 48 radiologists at 4 hospitals. Training included didactic and hands-on instruction covering 7 components:instrument alignment, hand/transducer position, forceps use, foreign body definition, forceps grasp, recognition of volumeaveraging, and oblique cross cut artifact. Pre-training testing assessed removal of a single toothpick imbedded in a turkey breast in15 minutes. Post-training evaluation consisted of 5 toothpick removals. Ongoing clinical implementation of USFBR includes foreignbody removal under ultrasound guidance by a trained radiologist. Parameters including age of patient, which radiologist, removalsuccess, type and size of foreign body, incision size, foreign body retention time, reason for removal, symptoms, modalities used indetection, wound closure, and sedation are recorded. Data were analyzed using chi-squared and Fisher's exact tests for categoricaloutcomes and analysis of variance for continuous outcomes.

RESULTS

After training, radiologists' scores improved from 21-52% pre-training to 90-100% post-training (p<0.001 for each component).Clinical to date, USFBR has been 100% successful in 7 (25 expected) patients, ages 9-73 years, by 4 trained radiologists. Objectsremoval length 4 to 30 mm, retention time 2 to 864 days, incision 2 to 8 mm. 1 closure. 1 sedated.

CONCLUSION

Ultrasound guided foreign body removal approach taught in simulation improves radiologist technique and removal outcomes. Aradiologist who completes simulation training can remove a variety of imbedded foreign bodies.


USFBR can be used to remove foreign bodies while minimizing patient discomfort and potential tissue damage.

ParticipantsStephen A. Balfour, MD, Philadelphia, PA (Abstract Co-Author) Nothing to DisclosePratik S. Patel, DO, Philadelphia, PA (Presenter) Nothing to DiscloseXi Xue, Philadelphia, PA (Abstract Co-Author) Nothing to DiscloseJustin McCloskey, BA, Pittsburgh, PA (Abstract Co-Author) Nothing to DiscloseDavid S. Pryluck, MD, MBA, Philadelphia, PA (Abstract Co-Author) Nothing to Disclose

PURPOSE

Prior studies have described the use of low-cost gelatin phantom models to train ultrasound-guided procedures, however, there islimited data evaluating their use in training CT guided procedures. The purpose of this study is to evaluate the use of such a modelto train inexperienced operators to perform CT guided abscess drainages.


Twenty inexperienced and blinded participants were asked to place a needle into a simulated abscess in a gelatin phantom followedby a pigtail catheter using Seldinger technique. Subjects were randomized to receive traditional didactic instruction prior to testingor to receive hands-on training with the phantom model prior to testing. Primary endpoints included time to successful needle, wire,and drain placement, number of scans to achieve needle placement, and total number of scans. Secondary endpoints included aLikert-type confidence survey.

RESULTS

Experimental subjects required fewer scans to achieve needle placement (4.7 vs 9.2, p=0.04) and less time to achieve needleplacement (14.7 vs 20.4 minutes, p = 0.04), compared with control subjects. Experimental subjects also felt more confident in theirability to safely (p=0.03) and successfully (p=0.01) perform the procedure on an actual patient. There was no significant differencebetween groups for total number of scans and time to successful wire/drain placement.

CONCLUSION

Our data demonstrate that the use of low-cost gelatin phantom models for the training of CT-guided procedures improves bothperformance and confidence in technically inexperienced subjects with the potential to reduce radiation dose.


We believe gelatin phantom simulation has real potential to serve a larger role in medical student and resident training.

ParticipantsDmitry Trifanov, MD, Boston, MA (Presenter) Nothing to DiscloseTaj Kattapuram, MD, Boston, MA (Abstract Co-Author) Nothing to DiscloseHaiyang Tao, MD, Boston, MA (Abstract Co-Author) Nothing to DiscloseRonald S. Arellano, MD, Boston, MA (Abstract Co-Author) Nothing to DiscloseRaul N. Uppot, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose

PURPOSE

The purpose of this study is to evaluate the role of electromagnetic navigational guidance system (EMN) and a phantom as trainingsimulator for computed tomography (CT)-guided procedures.


The study included two components: 1. A skills test using a navigational guidance system and phantom that simulated a CT-guided

SSQ21-05 Interventional Radiology Fellowship Websites: A Critical Analysis of Content and Accessibility


SSQ21-06 The Impact of a Laser Navigation System (LNS) on CT-guided Interventions


procedure. 2. A survey of the fellows assessing the use of a navigational guidance system on a phantom as a potential tool to helptraining for CT-guided procedures. Nineteen fellows (12 interventional radiology fellows and 7 abdominal imaging fellows) wereinvolved in the study.

RESULTS

Use of the EMN system improved the successful number of attempts at hitting the biopsy target for both the diagnostic andinterventional group. Mean number of successful attempts for all the fellows in the manual/conventional CT guidance group was58.8%. Mean number of successful attempts for all the fellows in the EMN group was 85.9%. Although there was improvement innumber of successful attempts using the EMN system compared to manual conventional method, there was no statisticallysignificant difference in time or accuracy. The pre and post survey showed no correlation was found between their confidence andaccuracy and only half of the fellows disclosed that their confidence improved after the training session. However 92.9% of thetrainees felt that using EMN system and phantom are useful training tools to simulate CT-guided procedures.

CONCLUSION

Use of EMN system on a phantom is a potentially valuable training tool for training and simulating CT-guided procedures for fellows.When using EMN navigational guidance, the number of the successful attempts by the diagnostic fellows, was significantly betterthan the interventional fellows. There was significant improvement in number of successful attempts for all fellows when the EMNsystem was used compared to manual/conventional targeting. In addition, nearly 93% of the fellows reported that use of the CT-simulator helped with training as it helped in understanding the spatial orientation necessary for CT-guided procedures.


Use of EMN systems on a phantom can help simulate and train residents and fellows for CT-Guided Procedures. These simulatedenvironments can help with patient safety.

ParticipantsResmi Charalel, MD, New York, NY (Presenter) Nothing to DiscloseBradley B. Pua, MD, New York, NY (Abstract Co-Author) Nothing to DiscloseNaveen Galla, BA, New York, NY (Abstract Co-Author) Nothing to DiscloseSamir Trehan, MD, New York, NY (Abstract Co-Author) Nothing to DiscloseDavid C. Madoff, MD, New York, NY (Abstract Co-Author) Nothing to Disclose

PURPOSE

To evaluate the content and accessibility of interventional radiology (IR) fellowship program websites.


All IR fellowship programs listed on the Society of Interventional Radiology (SIR) website were individually evaluated based oncontent and ease of access. Upon review of the SIR website, program contact information, application information, programdescription and website address were evaluated. A Google search was performed ("[program name] interventional radiologyfellowship") and the number of mouse clicks required to get from Google to each fellowship website was recorded. Each fellowshipwebsite was evaluated for detailed program characteristics, application information and specific contact information. Online datawas collected in November 2014.

RESULTS

Of the 85 programs listed on the SIR website, 95% (81/85) were currently offering fellowships and 96% (78/81) of these programshad functioning websites. All programs listed a contact telephone number and mailing address on the SIR website. However, noprogram had a functional link to the fellowship website from the SIR website. Via Google, it took an average of 1.1 clicks to accessavailable websites. Program description, application information and rotation schedule were provided in 86% (67/78), 72% (56/78)and 18% (14/78) of websites, respectively. Only 31% (24/78) of programs indicated on their websites that they acceptedapplications via ERAS. Additional factors such as didactics, current fellow information, and research opportunities were available in32% (25/78), 15% (12/78), and 33% (26/78), respectively.

CONCLUSION

The SIR website maintains a comprehensive listing of IR fellowship programs, most of which could be efficiently accessed viaGoogle. While most fellowship program websites contained a program description, other content such as application information androtation schedule, were less frequently present.


Interventional radiology (IR) fellowship will soon be replaced by its own residency. During this process, it will be increasinglyimportant to understand the information available to applicants on program websites and how to improve them.

ParticipantsMaurice Pradella, MD, Basel, Switzerland (Presenter) Nothing to DiscloseTobias Heye, MD, Basel, Switzerland (Abstract Co-Author) Nothing to DiscloseMartin Takes, MD, Basel, Switzerland (Abstract Co-Author) Nothing to DiscloseDavid Buergler, Basel, Switzerland (Abstract Co-Author) Nothing to DiscloseChristoph J. Zech, MD, Basel, Switzerland (Abstract Co-Author) Research Grant, Bayer AG Speaker, Bayer AG Travel support, BayerAG Advisory Board, Bayer AG Speaker, Bracco Group Travel support, Bracco Group

PURPOSE

CT-guided biopsies, drainages as well as spinal nerve infiltrations are established minimal-invasive methods. The aim of this study

SSQ21-07 How Much Does an Interventional Procedure Actually Cost? Analysis Using Time Driven Activity BasedCosting


CT-guided biopsies, drainages as well as spinal nerve infiltrations are established minimal-invasive methods. The aim of this studywas to compare our results with a newly installed laser navigation system (LNS) to prior procedures.


In June 2014 a new CT scanner (Somatom Edge, Siemens Medical Solutions, Erlangen, Germany) as well as a LNS (Amedo 3D-LNS,Amedo, Bochum, Germany) were installed in our institution. We retrospectively analysed and compared all biopsies, drainages andinfiltrations from a 3 months period prior (2013) and after (2014) the installation. Lesion size, distance from skin, procedureduration, radiation dose (total CTDIvol), complications and clinical success were evaluated. Operators experience was categorizedbetween residents under supervision and consultants, with at least 5 years of experience in interventional radiology.

RESULTS

A total of 236 procedures were included of which 69.1 % were performed by experienced operators (2013: 111 (66.7%), 2014: 125(91.1%)).In 2014 80.5% of all interventions were performed by using the LNS. Experienced operators used the LNS in 81.3 % of allcases in 2014 vs. 72.7 % for inexperienced operators. There was no overall difference in size (12.4 cm2 vs. 12.7 cm2, p=0.93),duration (10.7 min vs. 10.5 min, p=0.91) or distance from skin (6.1 cm vs. 5.8 cm, p=0.37) between the two groups.Overallcomplication rate was 6.8 % (with LNS: 4.0 % vs. 8.9 % without LNS, p=0.14). Success rate was 97.0 % incl. 8.1 % unclear cases(96.0 % incl. 10.0% vs. 97.8 % incl. 6.7 %, p=0.46).In total the use of the LNS reduced the patients' radiation exposure by 47.9 %(30.1 mGy vs. 57.9 mGy, p<0.001). This effect was independent from experience (experienced operators: 30.4 mGy vs. 59.2 mGy,p<0.001; inexperienced operator: 26.7 mGy vs. 54.8 mGy, p=0.012).Interestingly the use of the LNS significantly reduced theprocedure's duration in the inexperienced group (4.0 min vs. 13.2 min, p=0.046).

CONCLUSION

Our data suggest that the use of a LNS can reduce the radiation dose significantly. This effect occurs independently fromoperator's experience. Furthermore there might be benefits in reducing the procedure's duration in the group of inexperiencedoperators.


Dose reduction is an important factor in interventional radiology both for the patient as well as for the physician involved.

ParticipantsAnand M. Prabhakar, MD, Somerville, MA (Presenter) Nothing to DiscloseDerek Haas, Boston, MA (Abstract Co-Author) Nothing to DiscloseNicole Bassoff, Boston, MA (Abstract Co-Author) Nothing to DiscloseKatelyn Brinegar, Boston, MA (Abstract Co-Author) Nothing to DiscloseH. Benjamin Harvey, MD, JD, Boston, MA (Abstract Co-Author) Nothing to DiscloseAlexander S. Misono, MD,MBA, Boston, MA (Abstract Co-Author) Nothing to DiscloseRobert L. Sheridan, Boston, MA (Abstract Co-Author) Nothing to DiscloseRahmi Oklu, MD, PhD, Boston, MA (Abstract Co-Author) Nothing to Disclose

PURPOSE

Time-driven activity-based costing (TDABC) is a strategic accounting tool that empowers health care systems to determine thecost of care delivery vis-à-vis process mapping. This information can be used to optimize the value of clinical processes andprotocols. This project applied TDABC analysis to understand the labor costs of dialysis-related interventional radiology procedures.


In this IRB-approved, HIPAA compliant study, 25 patients who presented to IR for fistulagram or dialysis access thrombectomy wereobserved from arrival to discharge from July-September 2014. The trained observers recorded the room idle time and the time thepatient spent with each staff resource throughout the patients stay. This data was used to estimate the average time spent byeach staff resource at each step in the care process, and the value per minute of each staff resource (capacitance cost) wascalculated using publically available salary information. Based on these two factors, as well as equipment and room costs, the totalcost of each procedure was calculated. The data were analyzed with descriptive and comparative statistics.

RESULTS

Of the patients in the study, 16 underwent a fistulagram and 9 underwent a thrombectomy. The mean times were: 75±49 (roomidle time), 25±12 min (prep time), 90±46 min (IR fellow time), 124±46 min (IR Attending time), 15±5 min (room cleaning time), and142±45 min (total procedure time). Staff utilization rates for thrombectomy and fistulagram were: 47%/32% (IR Attending),52%/45% (IR Fellow), 67%/66% (IR Nurse), and 74%/75% (IR Technologist). Using salary estimates, the staff capacitance costswere: $4.10/min (IR Attending), $1.46/min (IR Nurse), $1.12/min (IR Tech), and $0.76/min (IR Fellow). The mean fistulagram costwas $563±199 with a 3.6x variation between the min ($302) and max ($1073) cost and the mean thrombectomy cost was$1103±430 with a 3.1x variation between the min ($598) and max ($1851) cost.

CONCLUSION

TDABC analysis demonstrates wide variability in the costs associated with dialysis-related procedures. Improvement of staffutilization rates is a strategy for reducing these costs.


TDABC is a novel way to cost healthcare procedures. Efforts aimed at improving staff utilization could reduce procedural costs forhealth care systems and increase their likelihood of success under risk-share payment models.

SSQ21-08 Effect of Patients' Negative Affect on Adverse Events in Interventional Radiology


SSQ21-09 Lead Aprons: A Lead Exposure Hazard?

Thursday, Dec. 3 11:50AM - 12:00PM Location: E352

ParticipantsNadja Kadom, MD, Boston, MA (Presenter) Nothing to DiscloseGheorghe Doros, Boston, MA (Abstract Co-Author) Nothing to DiscloseElvira V. Lang, MD, Brookline, MA (Abstract Co-Author) Founder and President, Hypnalgesics, LLC;

PURPOSE

Self-fulfilling prophecy of thoughts and feelings about health outcomes and the mood contagion between patients and physiciansare contested topics in the current literature and lay press. In this study we assessed whether a patient's negative affect ispredictive of adverse events during interventional radiological procedures.


This IRB-approved HIPPAA compliant study includes 230 patients who underwent percutaneous peripheral vascular and renalinterventions in a randomized sequence. Prior to their interventions patients filled out the Positive Affect Negative Affect Schedule(PANAS), rating 10 adjectives each related to either positive affect (PA) or negative affect (NA) using a 5-point rating scaleranging from "1=Very slightly/Not at All" to "5=Extremely". Adjectives fo NA were: Distressed, upset, guilty, scared, hostile, irritable,ashamed, nervous, jittery, and afraid. Adjectives fo PA were: Interested, excited, strong, enthusiastic, proud, alert, inspired,determined, attentive, and active. Adverse events included prolonged hypoxia, hypertensive or hypotensive episodes, prolongedbradycardia, postoperative bleeding. Summary scores for NA and PA were split into high and low over theirs medians and correlatedwith absence or presence of adverse events using logistic regression. Odds ratios, standard error (SE), confidence intervals (CI),and p-values were reported using SAS 9.1.3.

RESULTS

Patients with high NA had significantly more adverse events than those with low NA (22% vs 12%; odds ratio 0.48, SE 0.17, CI0.23 - 0.97, p=0.04). The degree of PA did not significantly affect outcome (odds ratio 0.76, SE 0.27, CI 0.38 -1.53, p=0.44).

CONCLUSION

Patients with high negative affect fared significantly worse in terms of adverse events as compared to patients who had lownegative affect. The degree of positive effect did not make significant difference.


The mood contagion from the patient's negative affect should be of concern for the practicing interventional radiologist because itmay result in a self-fulfilling prophecy of a negative outcome.

ParticipantsKevin Burns, MD, Bronx, NY (Presenter) Nothing to DiscloseMorri Markowitz, MD, Bronx, NY (Abstract Co-Author) Nothing to DiscloseBenjamin Taragin, MD, Teaneck, NJ (Abstract Co-Author) Nothing to DiscloseJamie Shoag, BS, Bronx, NY (Abstract Co-Author) Nothing to DiscloseSukhraj Kahlon, BS, Bronx, NY (Abstract Co-Author) Nothing to Disclose

PURPOSE

Lead (Pb) is highly toxic but is useful to protect against ionizing radiation. The lead inside shields worn by medical workers has longbeen believed to be nonhazardous. This study was designed to determine, for the first time, whether such shields expose wearersto lead in dust on exterior shield surfaces.


This was a descriptive study of a convenience sample of 172 shields. Both surfaces of each shield were tested in 2 ways: aqualitative on-site test (LeadCheck, 3M) and a lab based quantitative dust sample analysis by atomic absorption spectroscopy(AAS) expressed in micrograms per foot squared (ug/ft2). Age, type of shield, Pb sheet thickness, storage method and visual andradiographic appearance were assessed.

RESULTS

86 shields [50% (95% CI: 43-57%)] tested positive for surface lead using the qualitative method on one or both sides. 109 [63%(95% CI: 56-70%) of the shields had detectable lead by AAS. Pb dust by AAS ranged from undetectable to 998 ug/ft2. Comparingassessment methods, the positive predictive value of the qualitative method was 85%; negative predictive value was 58% versusthe quantitative method. There was 82% agreement as to the presence of Pb between the 2 sides, e.g., if Pb was present on onesurface it was likely present on the other. The quantitative detection of Pb was significantly associated with: 1) visual appearanceof the shield (1-best, 3-worst): 90% of shields that scored 3 had detectable dust Pb; 2) type of shield: a greater proportion of thepediatric patient, full body and thyroid shields were positive than vests and skirts; 3) use of a hangar for storage: 4 of 14 shieldson hangers (27%) were positive vs. 66 of 105 not on hangers (67%). Radiographic determination of shield intactness, thickness ofinterior Pb sheets, and age of shield were unrelated to presence of surface dust Pb. Of note, 5/5 shields constructed with nointerior Pb had no detectable surface Pb.

CONCLUSION

63% of shields had detectable surface lead which was associated with visual appearance, type of shield, and storage method. Aclinical correlate study, currently in progress at our institution, will help to assess risk to patients and clinicians.


Lead shields, long thought to be safe, have lead dust on external surfaces. Lead dust is a known source of exposure that can result

in lead poisoning and should be minimized as much as possible.

QS130-ED-THA1

Leading a Multi-specialty Quality Improvement Project: Implementing a Standardized Radiograph andMRI Reporting System for Suspected Pedal Osteomyelitis to Guide a Clinical Management Algorithm ina Large Teaching Hospital

Station #1

QS132-ED-THA2

Management of Critical Imaging Result Communication in an Academic Setting: Assuring Timely andAccurate Communication Using a PACS-Integrated Notification System

Station #2

QSE-THA

Quality Storyboards Thursday Poster Discussions

Thursday, Dec. 3 12:15PM - 12:45PM Location: QS Community, Learning Center


Participants

Sub-Events

ParticipantsGregory H. Broering, MD, Houston, TX (Presenter) Nothing to DiscloseStephen C. Liaw, MD, Houston, TX (Abstract Co-Author) Nothing to DiscloseAndrew R. Palisch, MD, Houston, TX (Abstract Co-Author) Nothing to DiscloseMarc H. Willis, DO, Houston, TX (Abstract Co-Author) Nothing to Disclose

PURPOSE

Improve diagnostic certainty, decrease unexplained clinical variance and improve ordering provider satisfaction with imaging reportsin the setting of suspected pedal osteomyelitis via improved standardization of stated specificity of diagnosis and terminology toguide patient management.

METHODS

A multi-specialty quality improvement project was initiated utilizing the IHI Model for Improvement. Project leaders initiallyperformed a needs assessment, identified potential barriers, defined the scope of the project, and engaged key stakeholders. Wehad not received requests for standardization, but our project leaders hypothesized that per the Kano Model, we could achieve thehighest level of customer satisfaction by providing customer delight via an unexpected customer satisfier. A literature review wasperformed. Thereafter, an evidence-based system was designed to best guide management of patients with the initial presentationof suspected pedal osteomyelitis. The goal of the system was to standardize terminology and report impressions to decreases inter-observer variability, eliminate ambiguous terminology, and provide definitive actionable recommendations. These standardimpressions were matched to the clinical algorithm being utilized to manage diabetic foot wounds. Key stakeholders from thedepartments of orthopedics, infectious disease, and the wound center were included to obtain feedback and facilitate collaboration.Patients with initial negative radiographs underwent wound care and follow-up radiographs in six weeks. Patients with positiveradiographs proceeded to MRI to define the extent of their osteomyelitis. At six week follow-up, in the setting of poor woundhealing and high clinical suspicion of osteomyelitis, MRI was performed to evaluate for underlying osteomyelitis. MRI findings werecategorized into four groups based on the probability of osteomyelitis (consistent with osteomyelitis, high probability ofosteomyelitis, low probability of osteomyelitis and no MRI evidence of osteomyelitis) based on T1, T2 and enhancementcharacteristics of the bone marrow. Paper and electronic copies of the stratification system were made available to all radiologystaff and residents. Retrospective data analysis was performed for three months prior to implementation. Data analysis was alsoperformed for the three months after implementation.

RESULTS

The data set consists of forty radiographic studies and forty MRI studies before and after implementation. Previously there was nosystem for reporting radiographs or MRIs for this patient population. We were able to achieve compliance with this reporting systemin 65% of cases, the majority were radiographs, likely due to the larger pool of interpreting radiologist. Improved compliance will bea focus item for the next PDSA cycle. Through this system, ambiguous impressions decreased from 27.5% to 10%, softrecommendations decreased from 37.5% to 15%, and definitive actionable recommendations increased from 5% to 25%. Orderingprovider feedback from orthopedics, infectious disease and the wound center has been extremely positive. A customer satisfactionsurvey will be performed at six months after implementation of this system.

CONCLUSION

Radiologist can successfully lead multi-specialty quality improvement projects that guide patient management by providing radiologyreports with standardized terminology, impressions and recommendations. Matching this output to evidence-based clinicalalgorithms provides a tremendous amount of value for patient management, the ordering providers, and the healthcare system.

ParticipantsTeddi H. Berry, MD, Jackson, MS (Presenter) Nothing to DiscloseJohn T. McCarty, DO, Jackson, MS (Abstract Co-Author) Nothing to DiscloseCyrillo R. Araujo, MD, Jackson, MS (Abstract Co-Author) Nothing to DiscloseFrederico F. Souza, MD, Madison, MS (Abstract Co-Author) Nothing to DiscloseWendy Howell, Jackson, MS (Abstract Co-Author) Nothing to Disclose

PURPOSE

Inability to relay critical imaging results to the appropriate clinician in a timely, efficient manner represents a significant potentialsource of medical error. Failure to appropriately document communication of critical results as well as failure of the clinical serviceto act on critical results was observed in our institution. The radiology department implemented a commercially available critical

QS134-ED-THA3

Quality Improvement and Patient Safety by Decreased Reject Scan

Station #3

QS010-EB-THA

Using Lean Principles to Optimize Breast Imaging/Surgery Interface and Improve Efficiency andWorkflow

Hardcopy Backboard

result notification system integrated into PACS in an effort to reduce errors/miscommunication. The system was underutilized priorto implementation of a departmental communication policy.

METHODS

In January 2014, our radiology department created a policy to use a commercially available software to relay and document criticalresults with the goal of improving the speed and accuracy of imaging critical result notification. Additionally, use of this notificationsystem standardizes the communication of critical results in our institution.Common critical results were categorized into three maincategories: yellow, orange, or red. Yellow results require clinician notification within 24 hours and comprises of incidental orunexpected findings that frequently need follow-up imaging. Orange results are more urgent and require notification within 12 hours.The red category is reserved for critical results that require urgent notification (within 60 minutes) and are often accompanied by aphone call to the ordering clinician. Separate notification categories were made for pulmonary nodules that required follow up andchest findings that were deemed suspicious for malignancy.A communication mechanism was created within the integratednotification system to ensure accurate documentation of clinician notification. The system allows the user to create a voicemessage that will be sent to the ordering physician. After a message has been sent, the name of the notified physician, date, andtime are automatically placed into the imaging report. If a phone call was placed to a physician, an option exists to document thecommunication without requiring a voice message to be sent.Two clinical outcome coordinators were also hired in radiology toensure appropriate physician notification, documentation of notification, and clinician follow-up of all messages created in thesystem.

RESULTS

There has been a dramatic increase in utilization of the notification system including all critical result categories since the policywas created in January 2014. In the 9 months previous implementation of the departmental policy, the average number of criticalresults entered into the system was 51 per month. Currently, we are averaging 700 closed total messages per month withincreased compliance by the radiologist, satisfaction by the referring provider and improving overall patient care.

CONCLUSION

A physician notification system was readily adopted by radiologists at the University of Mississippi and has been an effective way to"close the loop" when notifying clinicians of critical imaging results. As a result, critical findings are being relayed with increasedspeed and accuracy.

ParticipantsJaroonroj Wongnil, MSc, Bangkok, Thailand (Presenter) Nothing to Disclose

PURPOSE

Department of Radiology, Bumrungrad International Hospital performs more than 200,000 radiographs a year, for Thai andInternational patients. We found that each year the average of repeated x-ray was more than 6% of total x-ray proceduresperformed. To improve quality of radiograph and patient radiation safety, the department has set up the continuing qualityimprovement (CQI) team with the objective to reduce rate of repeated x-ray.

METHODS

The Fish Bone Diagram was used to identify causes of repeated x-ray which were from patient, radiology staff, work process, andequipment error. The collected data from computed radiography (CR) and digital radiography (DR) systems was analysed byperforming the Pareto chart to categorize causes of reject scan. The most frequently occurring exam types were found in Chest,Abdomen, L-S Spine, C-Spine, sinus and knee. Positioning error, poor inspiration and anatomy cut off were the most frequentlyoccurring reasons for rejection, accounting for 83.49% of rejects. The Plan-Do- Check -Act (PDCA) cycle was implemented toimprove the reject scan rates. Result feedback to management and staff was performed and technologist trainings in the mostfrequently occurring exam types were performed. The positioning aid was created as an innovation. The number of repeated x-raysfor each technologist was analysed by scatter plot. From the scatter plot, technologists were characterised by number ofperformed x-ray and reject scan into 4 categories of A, B, C, and D which group A was high volume -high reject , B was lowvolume-high reject, C was low volume-low reject, and D was high volume-high reject. The technologists who were in categories Aand B were enrolled in a comprehensive training to reduce their own reject scan rates..

RESULTS

The total reject scan decreased from 6.8 % to 4.8 %.The percent of Reject scan of Chest, Abdomen, Sinuses, C- spine and Kneedecreased except L-S Spine, because the L-S Spine in Oblique position dificult to adjust and the order for x-ray in this postionincrease. Team discuss the problem by PDCA after that create innovation for adjust the position and learning tool. Lastly percentreject in L-S spine decreased. After comprehensive training program and individual feedback to staff, the scatter plot showed theincreasing of group C and D.

CONCLUSION

The percent reject scan decreased from 6.8 to 4.8 was resulted from technologist positioning training, develop tools for patientpreparation , many languages of key word to help technologist communicate to patient for cooperation during X-Ray shooting. Thedeveloping of guide book, workflow and empowerment of staff can decreased reject scan. The innovation can be occured in routinework by attempting to solve the problem systemaically and preventing not to recurrence.

ParticipantsTejas S. Mehta, MD, MPH, Boston, MA (Presenter) Nothing to DiscloseRoss Simon, Boston, MA (Abstract Co-Author) Nothing to DiscloseCatherine Kilroy, RN, BSN, Boston, MA (Abstract Co-Author) Nothing to Disclose

April Isaac Jefferson, MBA, Boston, MA (Abstract Co-Author) Nothing to DiscloseDonna Hallett, Boston, MA (Abstract Co-Author) Nothing to DiscloseMary Jane Houlihan, MD, Boston, MA (Abstract Co-Author) Nothing to DiscloseDorothy Sarno, RN, Boston, MA (Abstract Co-Author) Nothing to Disclose

PURPOSE

Up to 70% of breast cancer patients require imaging procedures immediately prior to surgery. With our current system, it wasdifficult and time consuming to coordinate imaging services (needle localizations and lymphoscintigraphy), operating room (OR) timeand surgeons' schedules. There was suboptimal utilization of resources (imaging equipment and ORs), delays on the day of surgery(DOS), and overall patient and staff dissatisfaction. Our goals were to: 1) Increase utilization of needle localization slots from 40%(current) to 80%; 2) Develop a standardized process for breast surgical cases requiring preoperative imaging; 3) Have proceduresstart and end on time; 4) Develop a means to track patient location/flow on DOS.

METHODS

A team of multispecialty stakeholders (nurses/nurse practitioners, physicians, and administrators) from Radiology, Surgery, andAnesthesia, met weekly for 8 weeks and then monthly for a total of 6 months. We used Lean principles to identify problems andexplore solutions:1) Value Stream Process Map: Review steps required to schedule a patient for surgery and steps the patient tookon DOS.2) Spaghetti Diagram: Physically walk the path the patients take on DOS.3) Patient input: Obtain feedback from patientswho went through current process.4) Impact/Difficulty Grid: Categorize problems, determining level of impact if solved and level ofdifficulty to implement.Metrics were measured prior to the start of this project and 6 months following implementation of changes.

RESULTS

Results: All identified problems could be grouped into 4 main categories.1. Scheduling -PROBLEM: Appointments for needlelocalization, lymphoscintigraphy, and OR were made by the surgeon's office and required calling 3 different numbers in 3 differentareas of the hospital.SOLUTION: The OR managed the patient on DOS. Select OR personnel were trained to schedule allappointments via a new integrated scheduling system.RESULT: Reduction in time to schedule by 80%, from initial 25-minutes/patient (range 20-30 minutes) to 5-minutes/patient (range 2-8 minutes).2. Imaging Time Slots/Openings -PROBLEM:Although there were ample needle localization and lymphoscintigraphy appointments, the timings were not coordinated to minimizethe time the patient spent in the hospital, or to the timings of OR availability. Some appointments were 'reserved' for selectsurgeons. There was underutilization of resources and equipment in imaging and the OR. Length of imaging time in nuclear medicinevaried based on physician preferences.SOLUTION: A new schedule was created pairing needle localization and lymphoscintigraphyappointments. All surgeons had equal access to appointments. Underutilized appointment slots were removed and new appointmentslots created at times of demand. Imaging in nuclear medicine was limited to set time.RESULT: Increase in utilization of needlelocalization slots from 40% to 65%.3. Transportation and Timeliness -PROBLEM: Imaging and surgical procedures were performed indifferent buildings and on floors. Use of hospital transport and lack of awareness to the complete path of the patient on DOSresulted in delays. The location of the patient at a given time was not always known.SOLUTION: Discussion with hospital transportrevealed that these patients were considered as 'outpatients' and thus 'less urgent' than 'inpatients'. Priority level of these patientsfor transport was modified. A table with all procedure appointment times was placed at the front of the patient's chart, so that allcaregivers were aware of the path and held accountable to time frame.RESULT: 80% reduction in overall delays. Prior tointervention 61% patients had no delays. After intervention 92% had no delays.4. Patient Check-In and Communication -PROBLEM:Check-in location for patients varied based on order of appointments. OR staff were not always aware of the location of the patientor where she was in the process, and patients were not always sure of where they were supposed to go at a giventime.SOLUTION: All patients were asked to check-in at a single OR holding area, regardless of which procedure they had first. Anoutline was created for employees and patients.RESULT: Reduction in delay of surgery start times by up to 60% (from 64 minutesto 27 minutes).

CONCLUSION

The success of this project, and others like it, requires a dedicated multidisciplinary team of stakeholders, the use of Lean principlesand an understanding of the entire process, not just what goes on in one's own department. Using these tools, small changes canresult in major improvements. Even if all goals are not met, it is important for the team to continue to work on these processes toachieve the desired goal, as our team is doing. We will continue to measure metrics and strive to achieve set goals.

QS131-ED-THB1

Implementation of a Lecture Series Based on the American College of Radiology AppropriatenessCriteria for Emergency Medicine Providers

Station #1

QS133-ED-THB2

PACS-Integrated System for Tracking Incidental Pulmonary Nodules in Order to Minimize the Numberof Patients Lost to Follow-up and Missed Diagnosis of Early Lung Cancer

Station #2

QSE-THB

Quality Storyboards Thursday Poster Discussions

Thursday, Dec. 3 12:45PM - 1:15PM Location: QS Community, Learning Center


Participants

Sub-Events

ParticipantsJohn P. Nazarian, MD, Cleveland Heights, OH (Presenter) Nothing to DiscloseJeff J. Farrell, MD, Scranton, PA (Abstract Co-Author) Nothing to DiscloseSalim E. Abboud, MD, Cleveland, OH (Abstract Co-Author) Nothing to DiscloseSoham V. Shah, MD, Cleveland, OH (Abstract Co-Author) Nothing to DisclosePeter C. Young, MD, Cleveland, OH (Abstract Co-Author) Nothing to DiscloseChristos Kosmas, MD, Cleveland, OH (Abstract Co-Author) Nothing to Disclose

PURPOSE

The selection of appropriate imaging studies in the emergency department setting has become increasingly important amidheightened pressures for cost containment and concern about patient radiation doses. The American College of RadiologyAppropriateness Criteria (ACR-AC) are evidence-based guidelines compiled to assist medical providers in making the mostappropriate imaging or treatment decision for a specific clinical condition. Familiarity with the ACR-AC will become increasinglyvaluable for clinicians as CMS moves to implement Clinical Decision Support (CDS) tools in the following years. On the other hand,studies in the literature have indicated that the proficiency of emergency medicine (EM) residents in choosing appropriate imagingstudies does not improve significantly over the course of their training. Implementation of a lecture series may therefore be usefulas a teaching tool to familiarize EM providers with the ACR-AC and expand their knowledge regarding ordering the most appropriateimaging studies. We developed a lecture series addressing ten common clinical scenarios in EM with the goal of increasing bothawareness and knowledge regarding the ACR-AC among emergency department providers.

METHODS

Prior to the lecture series and in order to establish the degree of familiarity of EM providers with ACR-AC, a four-item survey(SurveyMonkey; Palo Alto, CA) was sent out to clinical practitioners in the emergency department at our institution, includingresidents, attending physicians, and nurse practitioners. The survey assessed provider familiarity with the ACR-AC, comfort inselecting appropriate imaging studies, and attitudes regarding the use of scientific evidence and cost/resource considerations whenselecting imaging studies. Subsequently, a series of lectures were given to emergency department practitioners covering tencommon clinical presentations chosen by the EM chief residents. As of 04/06/15, lectures encompassing the following six topics hadbeen delivered to the emergency medicine department by radiology residents: head trauma, acute chest pain - suspectedpulmonary embolus, acute chest pain - suspected aortic dissection, acute pelvic pain in the reproductive age group, right lowerquadrant pain - suspected appendicitis, and suspected spine trauma. All lectures also included information regarding relativeradiation dose for the imaging examinations relevant to each topic. Identical pre- and post-test quizzes, consisting of threequestions on each topic, were given immediately before and following the lectures and the responses were recorded per level oftraining. Four additional lectures are scheduled to complete the series in April 2015; remaining topics include acute knee trauma,suspected abdominal abscess, suspected small bowel obstruction, and acute vision loss.

RESULTS

The pre-lecture survey indicated a relatively low level of provider familiarity with the ACR-AC, with 23/38 respondents (61%)indicating that they had never heard of the ACR-AC. In spite of this, most providers (30/38, 80%) provided a response of either"agree" or "strongly agree" when asked if they feel comfortable selecting the most appropriate imaging modality to work up commonemergency complaints. Significant majorities of respondents also expressed agreement that it is important to use evidence-basedmedicine when choosing which imaging study to order (35/38, 92%) and that it is important to incorporate cost considerations andawareness of resource limitations when ordering studies (31/38, 82%). Data obtained from the pre- and post-lecture quizzesdemonstrated strong gains in knowledge by the emergency department providers after the ACR-AC lectures. An average of 25participants submitted quizzes on each topic. Aggregation of all quiz question results (n = 18 questions) collected thus far showedan improvement from 56% on pre-lecture quizzes to 81% on the post-lecture quizzes. Improvements were also noted in everyindividual topic: head trauma (from 57% to 87%), pulmonary embolus (from 58% to 83%), aortic dissection (from 49 to 77%), pelvicpain in reproductive age patients (from 50% to 84%), RLQ pain/appendicitis (from 78% to 88%), and spine trauma (from 45% to67%). Improvement was also seen at each level of training: PGY-1 (from 57% to 82%), PGY-2 (from 55% to 84%), and PGY-3(from 62% to 81%).

CONCLUSION

Implementation of a lecture series based on the ACR-AC can familiarize EM providers with the ACR-AC and improve their knowledgeabout diagnostic imaging study selection. Given the positive reception from our EM department, we plan on continuing andexpanding the lecture series to cover more topics in order to further improve imaging utilization patterns in our emergencydepartment.

Participants

QS016-EB-THB

Electronic Medical Record Integration for Streamlined DEXA Reporting

Hardcopy Backboard

Jason H. Williams, MD, Jackson, MS (Presenter) Nothing to DiscloseLindsey D. Halley, MD, Jackson, MS (Abstract Co-Author) Nothing to DiscloseDmitriy N. Kazimirko, MD, Madison, MS (Abstract Co-Author) Nothing to DiscloseCyrillo R. Araujo, MD, Jackson, MS (Abstract Co-Author) Nothing to DiscloseFrederico F. Souza, MD, Madison, MS (Abstract Co-Author) Nothing to DiscloseMelissa Stevens, Jackson, MS (Abstract Co-Author) Nothing to Disclose

PURPOSE

To improve management of incidental pulmonary nodules found on imaging studies by implementation of a PACS-Integrated systemto document and monitor patients for appropriate and timely follow-up.

METHODS

A departmental system was implemented and integrated within our PACS that utilized standard notification software to documentincidental pulmonary nodules and initiate a close-loop communication to the ordering physician or primary provider. A departmentalwide policy was also instituted on how and when to use the integrated pulmonary nodule communication system. Clinical outcomecoordinators within radiology then monitor the patients to ensure that appropriate and timely follow-up is obtained. A pulmonarynodule clinic was also started on the same timeframe by the pulmonologists to provide a referral option for the providers andpatients.

RESULTS

There has been an excellent acceptance and utilization of the notification system for pulmonary nodule communication by ourradiologists since the policy was created and the system was put in place in March 2014. Currently, we are averaging 90 totalpulmonary nodule messages per month with improved compliance by the radiologists and satisfaction by the referring providers. Allthe messages created in the system are being followed by our clinical outcome coordinators with no reported missed diagnosis oflung cancer due to lost patient follow-up with a previously identified pulmonary nodule on imaging. Multiple providers have alsocreated a care coordination position with someone responsible for checking up the pulmonary nodule messages and setting-upfollow-up appointments for their patients with pulmonologists or with the pulmonary nodule clinic.

CONCLUSION

Implementing a PACS-Integrated tracking system for documenting and following incidental pulmonary nodules found on imagingstudies can minimize communication failures and decrease the number of patients lost to follow-up. Additionally, closed-loopcommunication of pulmonary nodules and other critical imaging findings also improved significantly by simple observation, i.e.'Hawthorne effect'. Department-wide utilization of the system required hiring clinical outcome coordinators to managedocumentation and ensure appropriate follow-up of the created pulmonary nodule alerts/messages. Appropriate lung nodule follow-up guidelines and radiologist recommendations in the report alone do not reliably ensure adequate follow-up and management. Theaddition of closed-loop communication by a PACS-Integrated notification system and follow-up tracking by clinical outcomecoordinators offered the best management and follow-up strategies in our Healthcare Organization. This communication and follow-up tracking model can easily be replicated and implemented in other Hospitals and Healthcare Organizations.

ParticipantsJason W. Wachsmann, MD, Dallas, TX (Presenter) Nothing to DiscloseMatthew O. Thompson, MD, Dallas, TX (Abstract Co-Author) Nothing to DiscloseSolomon Cherian, MD, Dallas, TX (Abstract Co-Author) Nothing to DiscloseOrhan K. Oz, MD, PhD, Dallas, TX (Abstract Co-Author) Nothing to DiscloseTravis Browning, MD, Dallas, TX (Abstract Co-Author) Advisory Board, Hewlett-Packard Company; Advisor, McKesson Corporation

PURPOSE

Dual-energy X-ray absorptiometry is the most frequently performed examination to assess bone mineral density (BMD) in clinicalpractice. In our combined practice ~10,000 exams are performed per year in order to identify osteopenia or osteoporosis usingWorld Health Organization definitions. The primary output of DEXA exams is a group of numbers comprised of multiple BMD valuesand standard deviations that are displayed on a PACS workstation. These values are then manually dictated into the diagnosticreport. This manual process takes time and is prone to transcription errors. We proposed to export the DEXA numerical data via HL7engine to the EMR (Epic Systems, Verona, Wisconsin) to improve reporting efficiency and accuracy.

METHODS

The DEXA modality unit was reconfigured to export the report content via HL7 interface engine into the EMR. Header, footer, andpatient information were excluded from the DEXA-generated modality report and only report data was sent. This was accomplishedby mapping DICOM data (order ID and procedure code) into nonstandard fields (patient address and phone number fields) inside theDEXA modality. This allowed the HL7 interface to export the required information into the EMR. The HL7 interface engine was usedto force the preliminary status of the report and insert a generic placeholder provider name so the EMR would post this preliminaryresult message. Radiology interpretive reporting was done directly in the EMR, with note writing tools used to create the look andfeel of a traditional radiology report.In order to evaluate whether this change led to decreased errors, 100 preliminary DEXAradiology reports before the change and 100 after the change were examined. All reports went through a resident preliminaryreporting process. These reports were analyzed for errors that included decimal change, number transposition, negative numberissue, other incorrect number error, and failure to include prior exam for comparison. Errors by residents and errors by attendingphysicians for each report in each category were then tabulated and pre- and post-change scores were compared. In addition,report turnaround times were evaluated before and after the changes were made based on EMR timestamps for the different examstatuses (begin, end, preliminary, and final). Time evaluations included one year volume prior to change (3915 reports) and 1 monthpost change (206 reports).

RESULTS

Out of 100 DEXA exams before the change, 20 preliminary reports contained 44 errors and 15 final reports contained 25 errors withthe following breakdown: 7 with incorrect number in the preliminary report and 7 in the final report; 35 with other incorrect numberin the preliminary report and 18 in the final report; 2 with prior not listed for comparison and 0 in the final report. No decimal error

QS011-EB-THB

A Quality Improvement Initiative: Voice Recognition Report Quality Is Improved by Activating andUtilizing the Spell Check Feature

Hardcopy Backboard

issues or number transposition errors in the pre-change preliminary or final reports were identified. Out of 100 DEXA exams after thechange, only 1 preliminary report and 1 final report contained errors, and in both cases this included the prior not being listed forcomparison. Exam end to preliminary report time decreased from 1235 minutes to 0 minutes average (153 minutes to 4 minutesmedian). Exam end to final report time decreased from 2159 minutes to 625 minutes average (1252 minutes to 225 minutesmedian). Exam begin to final report time decreased from 2197 minutes to 670 minutes average (1278 minutes to 260minutesmedian).

CONCLUSION

Automating data transmittal from the DEXA modality into the EMR for reporting improves accuracy. Before implementation of thechange, 20% (20/100) of preliminary reports completed by residents were found to contain transcription errors, with 15% (15/100)with persisting errors at final report. After the change, only 1% (1/100) of preliminary reports was found to contain transcriptionerrors with 1% (1/100) persisting in the final report. Moreover, turnaround time report generation was improved from exam end topreliminary report, exam end to final report, and exam begin to final report.

ParticipantsRoyce Ruter, Rochester, MN (Presenter) Nothing to DiscloseAmy L. Kotsenas, MD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseAmanda Thiele, Rochester, MN (Abstract Co-Author) Nothing to DiscloseChris Fagerlind, Rochester, MN (Abstract Co-Author) Nothing to DiscloseJill Morrow, Rochester, MN (Abstract Co-Author) Nothing to DiscloseDana Soland, Rochester, MN (Abstract Co-Author) Nothing to DiscloseLaura Tibor, MBA, BEng, Rochester, MN (Abstract Co-Author) Nothing to DisclosePatricia Tackmann, BA, Rochester, MN (Abstract Co-Author) Nothing to DiscloseGina K. Hesley, MD, Rochester, MN (Abstract Co-Author) Research Grant, InSightec LtdGeoffrey B. Johnson, MD, PhD, Rochester, MN (Abstract Co-Author) Nothing to Disclose

PURPOSE

There was reluctance by radiologists at our institution to enable the spell check feature on our voice recognition software system.The radiologists feared common abbreviations might be flagged as errors, words would be difficult to add to the dictionary and thatthe pop-up message would become tedious. An internal benchmark of 97% error-free reports (for individual radiologists as well asthe cumulative department) was established and monitored with monthly audits of finalized reports. A quality improvement projectteam was formed to address two objectives: (1) decrease the spelling error rate by at least 25% and (2) verify if decreasing themisspellings improves the overall percentage of error-free reports.

METHODS

A multidisciplinary team representing various groups involved in voice recognition use and support as well as those performing thereport auditing process was commissioned to follow the Six Sigma DMAIC (Define-Measure-Analyze-Improve-Control) methodologyand set out to implement changes to address the objectives. During the define phase, a project charter and standard qualityimprovement tools including a stakeholder analysis and swim lane diagram helped capture the current state. In the measure phase,existing report audit data from the prior six months was used to decide metrics and track areas for possible improvement. The sameaudit process was followed for data collection and analysis for the baseline and post-implementation of enabling the spell checkfeature. A subset of daily finalized reports for each radiology division was audited (read) by a member of the auditing team(transcription). Members of this auditing team note the number of reports with errors in a spreadsheet for each radiologist and theinformation from the spreadsheets are automatically uploaded into a database each week. Reports with errors were placed in one ofthree categories; incorrect (this included any report requiring revision and notification was being sent to the provider),intrusion/omission and misspellings. For the analyze phase, the team brainstormed potential report improvement ideas, reviewed theoptions and used multi-voting to choose an idea felt to be most impactful. During the improve phase, we developed and performeda Plan-Do-Study-Act (PDSA) cycle, in essence piloting the change, to activate the automated spell check feature for all of theradiologists. A second PDSA cycle included creating an education document for adding words to the software dictionary andproviding just-in-time training to the users.The team documented the impact of the changes with quantitative data over threemonths, which was compared to the baseline data. Any qualitative feedback from users to the software support team was alsocollected. A change management plan was developed with communications occurring in multiple meetings, presentations and e-mailcommunication to all stakeholders about the data analysis, change and reason for change.

RESULTS

Baseline data analysis showed that 2.4% of the department's audited reports created with voice recognition software containedmisspellings. Additional baseline analysis demonstrated nearly a quarter of the radiologists (24.1%) were below the 97% error-freerate for the misspelling category and only 14% of the radiologists had enabled automated spell checking for their voice recognitionprofiles. Lastly, the department's cumulative baseline error-free report rate (encompassing all three report error categories) was94.7%.At the end of the 3-month PDSA, results showed improvements in all areas. Reports with misspellings had decreased by33%, the number of radiologists below the 97% error-free rate for the misspelling category was reduced by nearly half (12.3%remained below the benchmark) and all but one of the radiologists' voice recognition profiles continued to have automated spellcheck enabled. Finally, the department's cumulative overall error-free report rate improved to 95.4%. Qualitative feedback revealedthat there was little impact to the radiologists' workflow as the addition of words to the dictionary was a simple process and mostfrequently used words were incorporated within a matter of days after the spell check feature was enabled for all users.

CONCLUSION

Globally enabling the automated spell check feature in our voice recognition software decreased the number of reports withmisspellings, improved the overall number of error-free reports and introduced no significant radiologist workflow issues. We havenow made this a permanent change at our institution and recommend initiating the spell check feature for voice recognitionsoftware.

Honored Educators

Presenters or authors on this event have been recognized as RSNA Honored Educators for participating in multiple qualifying

educational activities. Honored Educators are invested in furthering the profession of radiology by delivering high-qualityeducational content in their field of study. Learn how you can become an honored educator by visiting the website at:https://www.rsna.org/Honored-Educator-Award/

Geoffrey B. Johnson, MD, PhD - 2015 Honored Educator

RCC54A Introduction to Business Analytics Demonstrating Application to Radiology

RCC54B Operational and Predictive Analytics in Radiology

RCC54C Capabilities of Current and Future Business Analytics Technologies

RCC54

The Use of Business Analytics for Improving Radiology Operations, Quality, and Clinical Performance (InAssociation with the Society for Imaging Informatics in Medicine)

Thursday, Dec. 3 2:30PM - 4:00PM Location: S501ABC

IN LM SQ


ParticipantsKatherine P. Andriole, PhD, Dedham, MA (Moderator) Advisory Board, McKinsey & Company, Inc;

LEARNING OBJECTIVES

1) Understand what is meant by business analytics in the context of a radiology practice. 2) Be able to describe the basic stepsinvolved in implementing a business analytics tool. 3) Learn how business analytics tools can be used for quality assurance inradiology, for maintenance of certification (MOC), and for practice quality improvement. 4) Be introduced to the capabilities ofcurrent and potential future business analytics technologies.

ABSTRACT

This course will provide an overview of the use of business analytics (BA) in radiology. How a practice manages information isbecoming a differentiator in the competitive radiology market. Leveraging informatics tools such as business analytics can help apractice transform its service delivery to improve performance, productivity and quality. An introduction to the basic steps involvedin implementing business analytics will be given, followed by example uses of BA tools for quality assurance, maintenance ofcertification (MOC) and pracitce quality improvement . The power of current business analytics technologies will be described, alongwith a look at potential future capabilities of business analytics tools.

Sub-Events

ParticipantsKatherine P. Andriole, PhD, Dedham, MA (Presenter) Advisory Board, McKinsey & Company, Inc;

LEARNING OBJECTIVES

1) Gain an overview of business analytics tools and understand how they might be used in radiology. 2) Be able to describe thegeneral steps involved in business analytics, including extract, transform, load (ETL) and key performance indicators (KPI). 3) See ademonstration implementation of an open-source business analytics tool using a radiology use case.

ABSTRACT

This session will provide a general overview of business analytics concepts and how they can be used in radiology. A walk throughof the basic steps involved in implementation including identifying, collecting, transforming, and dynamically presenting keyperformance indicators (KPI) will be demonstrated. The extract, transform, load (ETL) steps will be shown using an example usecase, and multiple database sources taken from a radiology practice.

ParticipantsPaul G. Nagy, PhD, Baltimore, MD, ([email protected]) (Presenter) Institutional license agreement, Analytical Informatics, Inc

LEARNING OBJECTIVES

1) Explain the big data science and radiology. 2) Identify the role of informatics in capturing, extracting, analyzing, andcommunication quality projects. 3) Illustrate graphical dashboarding examples to support quality efforts.

ABSTRACT

Honored Educators


Paul G. Nagy, PhD - 2014 Honored Educator

ParticipantsMindy Licurse, MD, Philadelphia, PA (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) To gain familiarity with currently available business technologies and their relevance to radiology practice. 2) To consider howexisting business technologies can support quality assurance in radiology. 3) To learn about business analytics features that maybe available/desirable in the future to augment and support both the practice of radiology.

ABSTRACT

MSCB52A Percutaneous Breast Biopsies

MSCB52B Radiologic-Pathologic Correlation

MSCB52C Performance Measures

MSCB52

Case-based Review of Breast (An Interactive Session)

Thursday, Dec. 3 3:30PM - 5:00PM Location: S100AB

BR SQ


ParticipantsJanie M. Lee, MD, Bellevue, WA (Director) Nothing to Disclose

LEARNING OBJECTIVES

1) Identify the appropriate application of multimodality breast imaging for routine screening, supplemental screening, and diagnosticindications. 2) Select appropriate methods for performing imaging-guided percutaneous breast biopsy and post-biopsy radiologic-pathologic correlation. 3) Calculate performance measure values for a breast imaging audit and compare with appropriatebenchmarks.

Sub-Events

ParticipantsWendy B. Demartini, MD, Madison, WI (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Understand the advantages and limitations of percutaneous breast biopsy. 2) Compare the different potential methods of coreneedle biopsy. 3) Apply techniques for the biopsy of routine and challenging cases using mammography, ultrasound and MRIguidance.

ABSTRACT

ParticipantsHeidi R. Umphrey, MD, Birmingham, AL (Presenter) Research support, General Electric Company

LEARNING OBJECTIVES


ParticipantsJanie M. Lee, MD, Bellevue, WA (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Identify the data to be collected and calculate performance measures for the basic clinically relevant breast imaging audit. 2)Compare audit results with appropriate performance benchmarks. 3) Understand additional data and calculations needed to performa comprehensive breast imaging audit.

RC723A MRI Conditional Pacemakers, What to Do?

RC723B Case Review of Real MR Safety Incidents

RC723C MRI Safety in the MR-Guided Interventional Environment

RC723

MR Safety II

Thursday, Dec. 3 4:30PM - 6:00PM Location: E352

MR PH SQ



ParticipantsMatthew A. Bernstein, PhD, Rochester, MN (Director) Research collaboration, General Electric Company

LEARNING OBJECTIVES

1) Classify MR conditional pacemakers, and describe guidelines for their clinical usage in the MR environment. 2) List several MRSafety incidents and describe their root causes. 3) Describe special MR Safety hazards present in the interventional MRenvironment, and identify countermeasures to reduce the associated risks. 4) Implement preventive measures for MR Safety in aclinical practice to improve the standard of care.

ABSTRACT

Sub-Events

ParticipantsAnshuman Panda, PhD, Phoenix, AZ (Presenter) Nothing to Disclose

LEARNING OBJECTIVES


ParticipantsArmen Kocharian, PhD, Houston, TX, ([email protected]) (Presenter) Research collaboration, General ElectricCompany

LEARNING OBJECTIVES


Active Handout:Armen Kocharian

http://abstract.rsna.org/uploads/2015/15002852/RC723B Case Review of Real MR Safety Incidents (1).pdf

ParticipantsKrzysztof Gorny, PhD, Rochester, MN (Presenter) Nothing to Disclose

LEARNING OBJECTIVES


RC724A Radiation Incidents in Diagnostic Radiology: What Does the Physicist Do Next?

RC724B Radiation Incidents in Radiation Oncology: What Does the Physicist Do Next?

RC724C Radiation Incidents in Diagnostic Radiology: What Does the Diagnostic Radiologist Do Next?

RC724

Near Misses and Errors in Diagnostic Radiology and Radiation Oncology: What to Do Next?

Thursday, Dec. 3 4:30PM - 6:00PM Location: S403B

RO PH SQ


ParticipantsMahadevappa Mahesh, MS, PhD, Baltimore, MD (Moderator) Author with royalties, Wolters Kluwer nv

ABSTRACT

Radiation incidents in diagnostic radiology and radiation oncology is never a favorite item for anyone. Many a times, a single error ormiss may lead to devastating result and can shine media spotlight. The purpose of this refresher course is to address this issuefrom various skate-holders. The course includes a tag-team of physicians-physicists addressing what one needs to next after aradiation incident occurs. The main objective of this refresher course is to provide ways audience can implement in their settings toaddress such events.

Sub-Events

ParticipantsMahadevappa Mahesh, MS, PhD, Baltimore, MD, ([email protected]) (Presenter) Author with royalties, Wolters Kluwer nv

LEARNING OBJECTIVES

1) To examine settings to ensure radiation incidents do not occur. 2) To develop plan of action for post radiation incidentevaluation. 3) To reflect on processes such as quality control, training etc.

ABSTRACT

Even though radiation incidents in diagnostic radiology may not be as life threatening as in radiation oncology, yet it is equallyimportant to devise plans of action to address radiation incidents in diagnostic radiology. This talk will discuss various measuresmedical physicists can do to address such situations.Defining radiation incidents in diagnostic imaging settings are key. Radiationincidents can lead to deterministic effects such as hair-loss or skin erythema, which are rare but possible due to prolongedfluoroscopy procedures or CT scans (CT perfusion studies) due to incorrect settings. Even though prevention is better and isachievable by routine review of equipment and protocol settings, but when radiation incidents occur, a physicist can do thefollowing. First, physicist should record details of scan settings that have led to the radiation incident. Next, it is important toassess and make necessary changes to the scan settings to avoid future incidents. This should be followed by detail assessment ofradiation exposure to patients (skin dose and organ dose) and work with the radiologists and other physicians to address theradiation events. In addition, tasks including regulatory compliance, staff training, and others will be discussed in this talk.

ParticipantsEric Ford, PhD, Seattle, WA, ([email protected]) (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Appreciate the systems-based approach to addressing the underlying causes of incidents. 2) Understand the medical physicist'sspecific role in this. 3) Gain familiarity with emerging error reduction tools in radiation oncology.

ABSTRACT

Incidents in healthcare are a symptom of an underlying condition. In order to improve the quality and safety of care one mustaddress these underlying conditions and not just the particulars of an incident itself. What is the physicist's role in this? In itssimplest form, the medical physicist in radiation oncology performs quality assurance tests and commissioning procedures to ensurethat the next incident does not happen. These tasks are often prescriptive in nature. As a quality management expert, though, themedical physicist's contribution extends far beyond these routine duties into the realm of understanding and controlling clinicalprocess at the broadest level. There is an array of emerging tools from the AAPM and elsewhere that enable this. It is now possible,for example, to characterize and quantify the risks associated with clinical processes. It is also possible to benchmark performancein safety-critical area against other clinics. And it is possible to participate in incident investigation and learning through the newlyreleased national incident learning system. All of these activities are core competencies of a medical physicist in radiation oncologyin the modern era. By leading and participating in such efforts the medical physicist has a direct impact on improving the qualityand safety of care.

ParticipantsKimberly E. Applegate, MD, MS, Zionsville, IN, ([email protected]) (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) To describe common incidents and their root cause in diagnostic radiology departments where patients are exposed tounintended radiation doses. 2) Understand both qualitative and quantitative metrics in a radiology safety program. 3) Provideexamples of quality assurance and improvement projects based on a safety event and that promote a culture of safety.

RC724D Radiation Incidents in Radiation Oncology: What Does the Radiation Oncologist Do Next?

ABSTRACT

Safety is necessary but not sufficient to ensure quality healthcare. Radiology departments and healthcare systems must be inalignment with their programs on safety culture, policies, and practice to best minimize patient harm. When events happen-andthey will-it is critical to understand how to disclose them, how to learn from them, and how to improve processes so that futurepatients in the system may not be harmed. Further, it is important that the culture of the radiology department embraces learningfrom near misses that provide the opportunity to improve practice before a patient is harmed. This lecture will share stories that ledto quality improvement projects.

ParticipantsNaomi R. Schechter, MD, Los Angeles, CA (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Describe strategies for responding to variety of potential near misses and errors in radiation oncology department as pertains toindividual patient care. 2) Describe strategies for learning from near misses and errors in radiation oncology department for purposeof quality improvement and prevention of future errors.

ABSTRACT

In a radiation oncology department, incidents can range from minor to severe. We take them all seriously. Due to our many checksand balances, it is unusual for an error to reach the patient. In the rare case that an error does reach the patient, most can becorrected for, with minimal if any harm to the patient. Our goal is to learn from every incident, review our processes and continuallyimprove the delivery of radiation therapy to prevent future errors from occurring.

RCC55A Overview of RadLex®

RCC55B 'RadLex Inside': Information Retrieval, Radiology Reporting, and Beyond

RCC55C ACR Usage of RadLex® Playbook for CT Dose Registry

RCC55

RadLex®: Overview of a New Lexicon for Radiology

Thursday, Dec. 3 4:30PM - 6:00PM Location: S501ABC

IN SQ


Participants

Sub-Events

ParticipantsKenneth C. Wang, MD, PhD, Ellicott City, MD, ([email protected]) (Presenter) Co-founder, DexNote, LLC;

LEARNING OBJECTIVES

1) Review the rationale for developing a lexicon for medical imaging. 2) See how an imaging lexicon can be used for education,research, and clinical reporting. 3) Understand the key technical factors in creating a complete and organized vocabulary formedical imaging. 4) Learn about the formats in which RadLex is distributed and the tools that are available for maintaining and usingterminology systems. 5) Discover how you can take advantage of RadLex in the development of radiology applications.

ABSTRACT

The purpose of the RadLex lexicon is to provide a uniform framework for indexing and retrieval of a variety of radiology informationsources, including teaching files, research data, and radiology reports. The RadLex lexicon unifies radiology terms from other medicallexicons, such as the ACR Index from the American College of Radiology, the Unified Medical Language System (UMLS) from theNational Library of Medicine, SNOMED-CT from the College of American Pathology, and the DICOM Content Mapping Resource. Thissession will explain the motivations for the creation of the RadLex imaging lexicon and describe RadLex-based applications instructured reporting, radiology information retrieval, image annotation, image navigation and decision support. RadLex technicalexperts will describe the formats in which RadLex is distributed, and will demonstrate some of the tools available to incorporateRadLex into the development of useful software applications. The RadLex Playbook system for standardized radiology procedurenames and codes will also be reviewed.

ParticipantsCharles E. Kahn JR, MD, MS, Philadelphia, PA, ([email protected]) (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Learn how the RadLex lexicon enables applications in radiology research, education, and clinical practice. 2) Describe how RadLexenables information retrieval. 3) Define the role of RadLex in RSNA's structured reporting initiative. 4) Discover new applications ofRadLex in radiology education and decision support.

Honored Educators


Charles E. Kahn JR, MD, MS - 2012 Honored Educator

ParticipantsKalpana M. Kanal, PhD, Seattle, WA, ([email protected]) (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Identify the challenge related to procedure code matching across institutions. 2) Describe the RadLex Playbook. 3) Explain howthe RadLex Playbook can be used to harmonize data across institutions.

RC816A Introduction and Overview of the Committee on International Radiology Education (CIRE)

RC816B Africa and the Middle East

RC816C Latin America

RC816D Asia Oceania

RC816

Radiation Safety Education around the World: An International Forum (Sponsored by the Committee onInternational Radiology Education)

Friday, Dec. 4 8:30AM - 10:00AM Location: S404CD

ED SQ


Participants

Sub-Events

ParticipantsTeresita L. Angtuaco, MD, Little Rock, AR, ([email protected]) (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) To define the role of the RSNA Committee on International Radiology Education (CIRE) in advancing radiology education throughits various programs. 2) To identify opportunities for radiology education in other countries especially those with the most need. 3)To list the different educational programs administered by the CIRE, the specific areas of emphasis of each program and thequalifications of candidates.

ABSTRACT

The RSNA Committee on International Radiology Education (CIRE) administers four educational programs each targeting a differentpopulation of radiologists. The International Visiting Professor program sends a team of radiologists with different areas of expertise,based on the needs expressed by the host country. The team lectures at national radiology society annual meetings, local hospitalsand teaching institutions during a two week period. The Derek Harwood Nash fellowship selects junior faculty within 10 years aftercompletion of training from all over the world who desire to have focused training on a specific radiologic specialty in an institutionchosen by the applicant. They train for 6-12 weeks in the U. S. insitution prior to returning to their countries. The Introduction toResearch for Young Academics selects international residents or fellows interested in academics. They join selected residents fromU.S. programs for one week of research workshops during RSNA week.. The Education Materials and Journal award program selectsinstitutions of learning from developing or newly-developed nations to receive gratis online or print subscriptions to Radiology andRadioGraphics in addition to other materials from the RSNA Education Center. Backgound information and updated data will beprovided for each program.

ParticipantsOmolola M. Atalabi, MBBS, Ibadan, Nigeria (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1)To outline the current practice of radiation safety in Africa and other developing world. 2) To outline challenges of radiationsafety in developing world and 3. Suggest ways in which the existing gaps in education on radiation safety and practice can bebridged.

ABSTRACT

Abstract: No doubt imaging equipment that use radiation has contributed immensely to the care of patients and the development ofdifferent types these equipment have been so rapid over the past 100 years. The dangers inherent in the use of the equipmentwhich are not only to patients but also to staff involved in the practice of imaging and therapy have been ignored for manydecades. Aggressive advocacy for adequate education on radiation safety however began in the last few years in the developedworld and rapidly gained ground and acceptance through 'Image gently and Image wisely' campaigns but the developing world havebeen left behind.This presentation will look at the current state of radiation education and practice vis-à-vis who is authorized towork with equipment that use and patients. What are the required type, level, frequency of training, and credentials orcertifications needed. What regulatory bodies are in place both locally and nationally to ensure radiation safety practice. Whatempahsies are being laid on radation safety in the curriculum of medical students and residents? What is the way forward in orderto bridge the gap in radiation safety education and practice between the developing and developed world.

ParticipantsRenato A. Mendonca, MD, Sao Paulo, Brazil (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) Demonstrate how legislation in Latin American countries prioritizes and addresses radiation protection. 2) Review how radiologicalsocieties and alliances in Latin America are organized to influence the education of other health professionals and the public.

ParticipantsChamaree Chuapetcharasopon, MD, Bangkok, Thailand, ([email protected]) (Presenter) Nothing to Disclose

RC816E Europe

RC816F Educational Initiatives in the United States

RC816G Global Collaboration in Radiation Safety Education

LEARNING OBJECTIVES

1) To discuss about the current situation of radiation safety practice in Asia Oceania. 2) To discuss about the current radiationsafety educational programs in Asia Oceania.

ABSTRACT

Asian Oceania comprises of two continents. There are more than 70 countries in all Asian Oceania regions. The estimatedpopulation for Asia in 2014 is 4,426,683,000. The Population in Oceania is approximately 39,000,000.Despite the diversities, manyactivities and programs for radiation safety education have been established including many networks. This presentation will discusson the current situation of radiation safety practice in Asia Oceania as well as current radiation safety educational programs.

ParticipantsUlrich Bick, MD, Berlin, Germany, ([email protected]) (Presenter) Equipment support, Hologic, Inc; License agreement, Hologic,Inc; Royalties, Hologic, Inc; Equipment support, Toshiba Corporation; Institutional research collaboration, Siemens AG

LEARNING OBJECTIVES

1) To learn about activities in radiation safety education in Europe.

ParticipantsMahadevappa Mahesh, MS, PhD, Baltimore, MD (Presenter) Author with royalties, Wolters Kluwer nv

LEARNING OBJECTIVES

1) To outline educational initiatives on radiation safety education in the US. 2) To list available resources and how to accessradiation safety educational topics. 3) To examine how medical physicists and radiologists could coordinate efforts to improveradiation safety education.

ABSTRACT

Radiation safety can be examined from two different points of view namely, patient safety and staff safety. Radiation safetyeducation is key in addressing the radiation protection principles in any radiology practice. Radiation safety education is part of theradiology residents training programs in the US since residents are examined on various medical physics topics including radiationsafety education. Radiation safety training is also becoming part of ongoing training of interventional radiologists. This talk will focuson the various educational initiatives in the United States and the various resources available for radiation safety. This talk will alsodiscuss on how to develop and establish radiation safety education for all those utilizing radiation.

ParticipantsMiriam N. Mikhail, MD, Geneva, Switzerland (Presenter) Nothing to Disclose

LEARNING OBJECTIVES

1) To outline a global collaborative development and implementation model of radiation safety education. 2) To describe the roles ofand actions from international organizations and agencies in radiation safety education. 3) To list open access radiation safetyeducation resources. 4) To examine how radiologists could improve radiation safety education.

ABSTRACT

Successful application of radiation safety principles in radiology practice is a result of teamwork and collaboration between thestakeholders. Individual experts from professional organisations develop education resources based on scientific evidence andknowledge, organisations and agencies advocate for their adoption by regulatory authorities and radiology practices, andradiologists learn from these principles and use them in practice.Professional organisations such as the International Society ofRadiology, the Radiological Society of North America and United Nations agencies such as the World Health Organisation andInternational Atomic Energy Agency are some of the collaborators.The International Basic Safety Standards provide guidance toimprove radiology practice and radiation safety. The Bonn call-for-action identified priorities to improve radiation safety in the nextdecade. These recommendations include the strengthening of radiation safety education and training.Many open access radiationsafety education resources are available to radiologists. Radiologists play leading roles in the improvement of quality care andradiation safety through content development, training delivery and practical use of radiation safety measures and tools.

Active Handout:Miriam Niveen Mikhail

http://abstract.rsna.org/uploads/2015/15003258/Active RC816G.pdf

SST14-01 Automated QA Approaches to Monitor Low Contrast Performance for Computed Tomography (CT)and Digital Breast Tomography (DBT)

Friday, Dec. 4 10:30AM - 10:40AM Location: S403B

SST14-02 Low-contrast Detection in 80-, 100-, 120- and 140-kVp MDCT Protocols Using Adaptive StatisticalIterative Reconstruction-V technique: Diagnostic Accuracy, Image Quality, and Radiation Dose in aPhantom Study


SST14

Physics (CT VIII-Image Quality II)

Friday, Dec. 4 10:30AM - 12:00PM Location: S403B

CT PH SQ


ParticipantsXiaochuan Pan, PhD, Chicago, IL (Moderator) Research Grant, Koninklijke Philips NV; Research Grant, Toshiba Corporation; Ingrid Reiser, PhD, Chicago, IL (Moderator) Nothing to Disclose

Sub-Events

ParticipantsAustin Healy, MS, Greenwich, NY (Abstract Co-Author) Employee, The Phantom LaboratoryDavid J. Goodenough, PhD, Myersville, MD (Abstract Co-Author) Director, The Institute for Radiological Image Sciences, Inc;Consultant, The Phantom Laboratory; Consultant, Live Radiology, LLC; Consultant, Image Owl, IncHildur Olafsdottir, Salem, NY (Presenter) Research funded, Image Owl, IncRichard P. Mallozzi, PhD, Schenectady, NY (Abstract Co-Author) Employee, The Phantom LaboratoryJesper Fredriksson, Salem, NY (Abstract Co-Author) Employee, Raforninn ehf

PURPOSE

An important attribute of medical imaging systems is Low Contrast (LC) performance which is known to have many caveats inmeasurement and interpretation. This study uses a number of commercial QA phantoms to investigate measures that might beuseful in a constancy sense in an automatic QA program.


Different modules of the Catphan® Phantom and Tomophan™ (The Phantom Laboratory, Salem, NY), present cylindrical andspherical targets of differing CT contrast and dimensions. Automated QA monitoring methods have been developed that calculatesignal (contrast) to noise ratios and related detectability models. These include Rose models of the ratio of target contrast totarget noise, predicted related Contrast-Detail (CD) diagrams, and results from applying matched filter models and other moreadvanced signal detection models. The same models are applied to cylindrical targets as well as spherical targets in both CT andDBT.

RESULTS

The automated results are presented and discussed for CT and DBT and compared to visual results from human observers. Withcare to identify non-uniformities and possible artifacts, the results are found to be quite reproducible and useful in a QA constancysense. Caution is urged, however, in extending such physics and QA techniques applied to well-defined targets in relatively uniformbackgrounds to the more complex case of more complicated structured clinical backgrounds with more non-uniformity.

CONCLUSION

Low contrast models can be used with automated approaches to produce reliable data on LC performance, at least in a QAconstancy sense. Several caveats involving the need to adjust for non-uniformities and/or artifacts need to be considered and anextension to the clinical domain must be approached with caution.


This study does not predict clinical low-contrast performance, but is useful in helping monitor scanner performance in a QA sense offactors such as statistical noise and edge resolution of targets.

ParticipantsRanish Deedar Ali Khawaja, MD, Salem, MA (Presenter) Nothing to DiscloseJustin B. Solomon, MSc, Durham, NC (Abstract Co-Author) Nothing to DiscloseYakun Zhang, MS, Durham, NC (Abstract Co-Author) Nothing to DiscloseMannudeep K. Kalra, MD, Boston, MA (Abstract Co-Author) Nothing to DiscloseDonald P. Frush, MD, Durham, NC (Abstract Co-Author) Nothing to DiscloseEhsan Samei, PhD, Durham, NC (Abstract Co-Author) Nothing to Disclose

PURPOSE

To compare the low-contrast detection (LCD), image quality, and radiation dose of a new, third-generation Adaptive StatisticalIterative Reconstruction (ASiR-V) methodology with a filtered back projection (FBP) at different tube voltages and radiation doses.


Images of a proprietary Mercury phantom (v3.0) obtained with five different clinically relevant incremental 12-37 cm phantom sizes

SST14-03 Tilt Angle Effects on Quality Control Phantom Measurements in Multi-Center CT Imaging Studies


SST14-04 Characterization of Tube Current Modulation in Terms of Transfer Functions with a Utilization forPerformance Evaluation and Noise Prediction


and low contrast-detail were acquired on a prototype 256-detector row CT (Revolution, GE Healthcare) using varying tubepotentials (80, 100, 120, 140 kVp) and a constant CTDIvol (3.0 mGy). A second set of scans was performed at 120 kVp with sixdifferent dose levels (0.7-24.0 mGy). Images were reconstructed using the FBP and the ASiR-V algorithms (at three strengths) attwo different slice thicknesses. Image quality was evaluated using detectability index [d' - a measure of LCD for a 5.0 mm, 200 HUcontrast lesion] as well as noise by comparing objective image noise on ASiR-V images to FBP images as a control. Statisticalanalysis was performed using ANOVA.

RESULTS

At variable kVps and a constant CTDIvol, a significantly higher d' was demonstrated at lower-kVp MDCT protocols using iodine-contrast media with either FBP or ASiR-V. At any given phantom diameter, d' for ASiR-V images was significantly higher than d' forFBP images (P<.01). This effect was distinct in smaller pediatric-sized phantom diameters (12 and 16 cm). ASiR-V showedsignificantly higher d' than across all radiation doses (0.7-24.0 mGy; P<.01). At the lower radiation doses (0.7-3.0 mGy), LCD wassignificantly better with only higher ASiR-V strengths (≥80%). Compared to FBP, a statistically significant reduction in objectiveimage noise was demonstrated [ASiR-V 50% (range, 24-38% noise reduction), ASiR-V 80% (37-58%), ASiR-V 100% (44-70%)].Percent decrease in noise was less with increasing phantom size and increasing CTDIvol.

CONCLUSION

ASiR-V iterative technology performed significantly better on low-contrast detectability and noise decrease rates compared to FBPtechnique at multiple kVp and radiation doses. This effect was amplified at both pediatric-sized phantom diameters, and at lowertube potential (such as 80 kVp using iodine contrast).


Across phantom diameters, especially with pediatric sizes, ASiR-V technology affords significant quantitative improvements in imagequality and lesion detection compared to conventional FBP technique.

ParticipantsJunfeng Guo, PhD, Iowa City, IA (Presenter) Shareholder, VIDA Diagnostics, IncChao Wang, PhD, Iowa City, IA (Abstract Co-Author) Nothing to DiscloseJohn D. Newell JR, MD, Iowa City, IA (Abstract Co-Author) Research Consultant, Siemens AG; Research Grant, Siemens AG;Consultant, VIDA Diagnostics, Inc; Stock Options, VIDA Diagnostics, Inc; Consultant, GlaxoSmithKline plc; Kung-Sik Chan, Iowa City, IA (Abstract Co-Author) Nothing to DiscloseEric A. Hoffman, PhD, Iowa City, IA (Abstract Co-Author) Founder, VIDA Diagnostics, Inc; Shareholder, VIDA Diagnostics, Inc;Advisory Board, Siemens AG; ;

PURPOSE

Several multi-center and longitudinal CT studies are relying on monthly scanning of the COPDGene 1 Phantom to monitor temporalstability of individual scanners. This study investigates the effects of imperfect object positioning and provides guide lines foracceptable tilt angles.

RESULTS

Using model (1) fitted to data with a Tilt Index up to 0.8, the acceptable Tilt Index was found to be smaller with denser material:0.4, 0.6, 0.7 and 0.7, for acrylic, water, lung-foam equivalent and air, respectively. The airway measurements and the MTF curveremain stable with Tilt Indices between 0 and 1.7.

CONCLUSION

Rotations of the COPDGene phantom with a tilt index above 0.4 will produce more than 1-HU shift in the mean density of at leastone material. Because of this, at the time of phantom receipt at a radiology core laboratory, quality control procedures shouldinclude an assessment of the Tilt Index. A Tilt Index threshold of 0.4 is recommended.


Quality control procedures in a radiology core laboratory should include an assessment of the Tilt Index. A Tilt Index threshold of0.4 is recommended.

ParticipantsYakun Zhang, MS, Durham, NC (Abstract Co-Author) Nothing to DiscloseJames Winslow, PhD, Durham, NC (Abstract Co-Author) Nothing to DiscloseEhsan Samei, PhD, Durham, NC (Presenter) Nothing to Disclose

PURPOSE

This study aims to develop a methodology to characterize the performance of tube current modulation (TCM) techniques in avendor-generic way, and to broaden a methodology to predict mA and noise for clinical images acquired by TCM.


The adult head and body cylindrical CTDI phantoms (16 and 32 cm in diameter respectively) were axially assembled together usinga long rod. All inserts were placed in the periphery holes to create a solid uniform phantom. The phantom was imaged on acommercial CT (Siemens SOMATOM Definition Flash) with a tube current modulation setting of 300 reference mA, I31s kernel, and 1mm thick slices. The output tube current for each slice was normalized by the pitch to obtain effective mA. This effective mA as afunction of distance, where the transition from small to large section occur, was used to obtain an edge spread function (ESF). The

SST14-05 Multi-slice Reading in a Low-Contrast Detection Task in CT: Correlation between Human and ModelObserver Performance


SST14-06 New Approaches to Determination of 3D Resolution in CT


ESF was numerically fitted using a smoothing spline method, differentiated, and Fourier transformed to obtain the mA transferfunction (mATF). Noise from each slice was also measured, plotted against the distance, and processed into a noise transferfunction (NTF). To validate the technique, a continuously varying sized phantom was used. The measured mA and noise from thevarying size of the phantom were compared to those predicted from the mATF and NTF method.

RESULTS

For the same pitch, mATF curves from different rotation times (0.5 s and 1 s) remained nearly identical. When pitch increased from0.5 to 1, the frequency at 50% almost halved from 0.027 to 0.015 1/mm. The average difference between predicted and measuredvalues was ~ 10% for mA, and ~ 20% for noise.

CONCLUSION

A mA and noise transfer function was proposed for characterization of tube current modulation. The transferfunctions can be usedto predict mA and noise properties of TCM scans. The mehodology was validated using a varying sized phantom.


A mA and noise transfer function was proposed for characterization of tube current modulation. The transfer functions can be usedto predict mA and noise properties of TCM scans.

ParticipantsLifeng Yu, PhD, Rochester, MN (Presenter) Nothing to DiscloseBaiyu Chen, Rochester, MN (Abstract Co-Author) Nothing to DiscloseJames M. Kofler JR, PhD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseChristopher P. Favazza, PhD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseShuai Leng, PhD, Rochester, MN (Abstract Co-Author) Nothing to DiscloseCynthia H. McCollough, PhD, Rochester, MN (Abstract Co-Author) Research Grant, Siemens AG

PURPOSE

Model observers based on 2D images have been used to assess CT image quality. However, radiologists typically read images bypaging through multiple slices. The purpose of this study was to correlate human and model observer performance in a low-contrastdetection task that involves multi-slice (MS) reading.


A low-contrast phantom containing 18 spheres (6 sizes x 3 contrast levels) was scanned on a 192-slice CT scanner at 5 doselevels (CTDIvol = 27, 13.5, 6.8, 3.4, and 1.7 mGy), each repeated 100 times. Images were reconstructed using both FBP and aniterative reconstruction method (ADMIRE, Siemens). A 3D volume of interest (VOI) around each sphere was extracted and placedside-by-side with a signal-absent VOI to yield a 2-alternative forced choice (2AFC) trial. 16 2AFC studies were generated, eachwith 100 trials, to evaluate the impact of radiation dose, lesion size and contrast, and reconstruction method. In total, 1600 trialswere presented to both model and human observers. Three medical physicists served as human observers and were allowed to pagethrough slices of the 3D volumes. A multi-slice channelized Hotelling observer (CHO_MS) was applied to the 16 2AFC studies.CHO_MS combined multi-slice responses through a separate Hotelling model. For comparison, the same 16 2AFC studies were alsoperformed in a static 2D mode by the 3 readers and a previously validated CHO (CHO_2D).

RESULTS

In the multi-slice viewing mode, observer performance was highly correlated between human observers and the CHO_MS (two-tailed Spearman's correlation coefficient R=0.96, p<0.01). Human observer performance varied between the MS and 2D modes. Onereader performed better in the MS mode (p=0.013); whereas the other 2 readers' performances showed no significant differencebetween the 2 modes (p=0.06 and p=0.38). The CHO_2D had a high correlation with human observers in both 2D (R=0.95, p<0.01)and MS mode (R=0.97, p<0.01).

CONCLUSION

A multi-slice CHO was shown to be highly correlated with human observers in a low-contrast detection task using multi-slicereading. For this task, a previously validated 2D CHO similarly predicted human observer performance for multi-slice reading of 3Dimages.


Human observer performance in multi-slice reading may be predicted by either CHO_MS or CHO_2D. These tools are useful forobjectively assessing and optimizing CT dose and system performance.

ParticipantsAustin Healy, MS, Greenwich, NY (Abstract Co-Author) Employee, The Phantom LaboratoryDavid J. Goodenough, PhD, Myersville, MD (Abstract Co-Author) Director, The Institute for Radiological Image Sciences, Inc;Consultant, The Phantom Laboratory; Consultant, Live Radiology, LLC; Consultant, Image Owl, IncJesper Fredriksson, Salem, NY (Abstract Co-Author) Employee, Raforninn ehf Hildur Olafsdottir, Salem, NY (Presenter) Research funded, Image Owl, IncJoshua Levy, Salem, NY (Abstract Co-Author) Stockholder, The Phantom Laboratory President, The Phantom LaboratoryStockholder, Image Owl, Inc

PURPOSE

The growing trend toward 3D imaging involving Volume CT scanners and the use of 3D and Multiplanar Reconstruction (MPR)

SST14-07 Optimization of CT Scan-mode and Reconstruction Kernel for Bone Fracture Detection Tasks


SST14-08 Quality Assurance in a Multicenter Trial Evaluating Quantitative CT Perfusion Imaging as a Biomarkerof Patient Outcome in Ovarian Cancer Chemotherapy: An ECOG-ACRIN and NRG GOG Study


The growing trend toward 3D imaging involving Volume CT scanners and the use of 3D and Multiplanar Reconstruction (MPR)techniques leads to the need for phantoms and test methods that reveal to the radiologist and physicist actual 3D resolution. Thatis, measures involving not only in-plane (x,y) resolution and related MTF's but also slice width and Slice Sensitivity Profiles (SSP).These "combined" effects can be studied with two new types of phantoms, the WAVE phantom and a 45° Resolution Gauge and areamenable to analysis by automated approaches.


Newly available commercial phantoms, the WAVE phantom and 45° Resolution Gauge (The Phantom Laboratory, Salem NY) aredesigned to incorporate the combined effects of in-plane (x,y) resolution as well as slice thickness (z) resolution. These testobjects can reveal the way in which the actual CT resolution can be limited by the choice of reconstruction filter and/or the slicethickness or SSP (z) used for the acquisition. Likewise, these phantoms can be used in direct 3D volume acquisition models and MPRor 3D reconstruction approaches. In the case of the WAVE phantom, automated analysis of the harmonics of an angled periodicstep wave can be used to show the combined resolution limitations of the in-plane point spread function and the SSP (z) of theslice thickness used in the acquisition.

RESULTS

Examples are shown of the use of the WAVE phantom and the 45° Resolution Gauge with Volume and Multislice (MS) CT scanners.Both the third harmonic of the WAVE and the cutoff of the 45° Resolution Gauge are shown for various acquisition protocolsinvolving different spatial resolution filters and different slice thicknesses. The limitations of using in-plane resolution filters whenusing a typical slice thickness of 1 to 5mm are clearly shown for several different volume and MS scanners.

CONCLUSION

Use of the new test methods and phantoms reveals useful information for 3D imaging on the combined effects of in-plane resolutionand the slice thickness used in the acquisition or reconstruction process. These results can influence the appropriate choice ofresolution filter and slice thickness in acquisition protocols.


New approaches give the physician a quantitative and qualitative (visual) measure of the combined effects of in-plane resolutionand slice thickness used in the acquisition or reconstruction process.

ParticipantsJuan Pablo Cruz Bastida, Madison, WI (Presenter) Nothing to DiscloseDaniel Gomez-Cardona, Madison, WI (Abstract Co-Author) Nothing to DiscloseKe Li, PhD, Madison, WI (Abstract Co-Author) Nothing to DiscloseTimothy P. Szczykutowicz, PhD, Madison, WI (Abstract Co-Author) Equipment support, General Electric Company Research Grant,Siemens AGGuang-Hong Chen, PhD, Madison, WI (Abstract Co-Author) Research funded, General Electric Company; Research funded, SiemensAG

PURPOSE

Hi-Res(olution) mode was recently introduced in some state-of-the-art CT systems to reduce view-angle aliasing and increasespatial resolution. Hi-Res mode allows users to reconstruct data using either conventional or High Definition (HD) kernels. Since highspatial resolution is often associated with a tremendous increase in image noise, the introduction of the Hi-Res mode confoundsscan mode selection and the associated reconstruction protocols. In this work we investigate the optimization of scan mode andreconstruction kernel selection for bone fracture detection


A quantitative, task-driven imaging performance assessment framework was used for optimization. Spatial resolution was quantifiedwith modulation transfer function (MTF) measurements using a tungsten bead. Similarly, the noise power spectrum (NPS) wasmeasured under different conditions with repeated scans, and the impact of display window and level was incorporated into theanalysis. A model observer was used to quantify the dependence of the overall imaging performance on different systemparameters, and to optimize mode and kernel selection. Model observer results were validated with an ex vivo animal experiment

RESULTS

(1) For conventional reconstruction kernels, the use of Hi-Res mode did not result in a major change in the MTF for centeredpositions, but it improved the MTF at off-centered positions. (2) The combined use of Hi-Res mode and HD kernels improved MTF atboth centered and off-centered positions. (3) The use of HD kernels increased noise magnitude and pushed the noise power tohigher frequencies. (4) The optimal kernel and scan mode strongly depend on fracture size and NPS. Model observer results werequalitatively verified by the ex vivo experimental results

CONCLUSION

Optimal use of the Hi-Res mode and its associated HD kernels depends on patient positioning and imaging task. Optimal decisionmaking for its use can be achieved based on the framework developed in this work


Despite its great potential in reducing aliasing and improving spatial resolution, Hi-Res mode has been underused clinically, mostprobably due to questions about how to optimize scan protocols for this technique. This work incorporates spatial resolution andnoise properties of Hi-Res mode and HD kernels along with specific diagnostic task functions to optimize reconstruction kernelselection

SST14-09 Quality Control Phantom Using 3D Printing Technology in Multi-modality System

Friday, Dec. 4 11:50AM - 12:00PM Location: S403B

ParticipantsTing-Yim Lee, MSc, PhD, London, ON (Presenter) Research Grant, General Electric Company Royalties, General Electric CompanyChaan Ng, MD, Houston, TX (Abstract Co-Author) Nothing to DiscloseSusanna I. Lee, MD, PhD, Boston, MA (Abstract Co-Author) Nothing to DiscloseMark A. Rosen, MD, PhD, Philadelphia, PA (Abstract Co-Author) Nothing to DiscloseFeng Su, PhD, London, ON (Abstract Co-Author) Nothing to DiscloseJoseph Bauza, Philadelphia, PA (Abstract Co-Author) Nothing to DiscloseZheng Zhang, PhD, Providence, RI (Abstract Co-Author) Nothing to DiscloseSusan M. Edwards, MD, Oklahoma City, OK (Abstract Co-Author) Nothing to DiscloseTherese M. Weber, MD, Birmingham, AL (Abstract Co-Author) Nothing to Disclose

Background

ACRIN 6695's primary objective was to determine whether CT perfusion (CTP) parameters are prognostic of progression-freesurvival at 6 months in a cohort of patients from the GOG-262 trial. The latter is a phase III trial on advanced stage ovarian cancercomparing standard to dose-dense paclitaxel/carboplatin with 91% of cohort also receiving bevacizumab. Multivariate analysis ofACRIN 6695 demonstrated association of CTP parameters with patient outcome. 76 subjects underwent 3 CTP studies comprised ofdynamic contrast enhanced using a two-phase scanning protocol: 24 images at 2.8 s intervals followed by 8 images at 15 sintervals acquired using 120 kV and 50 mAs each image. Axial shuttle scanning mode was allowed but not required. To ensureprotocol compliance and uniform image quality, a CT scanner certification process was implemented. Scanner accreditation requiredthat images of a water phantom scan acquired using the trial CTP protocol be submitted to a central core lab where they wereevaluated for the following variables: image interval, CT noise, spatial uniformity and temporal stability of CT number.

Evaluation

19 CT scanners from 4 vendors were accredited. The image intervals in both CTP phases were correct in all scanners. CT noisenormalized to 5 mm slice thickness was 10.1±1.6 HU. Spatial uniformity and temporal stability was 0.94±0.54 and 0.44±0.15 HUrespectively. Both CT noise and spatial uniformity were within 15% of vendor specifications for all accredited scanners.

Discussion

Important factors affecting the accuracy and precision of CTP derived functional parameters include image intervals, CT noise,spatial uniformity and temporal stability of CT numbers. The accreditation process for the ACRIN 6695 evaluated specifically thesefactors using a practical process which can be implemented by scanning a routine quality control water phantom already present atthe site with the specified protocol.

Conclusion

The ACRIN 6695 trial has demonstrated that CT scanner quality assurance for abdominopelvic CTP can be successfullyaccomplished with sufficient uniformity across multiple sites and scanner platforms to yield positive results in a multicenterbiomarker trial.

Honored Educators


Susanna I. Lee, MD, PhD - 2013 Honored Educator

ParticipantsByungdu Jo, Wonju-Si, Korea, Republic Of (Presenter) Nothing to DiscloseDohyeon Kim, Wonju, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseSu-Jin Park, Wonju, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseHyemi Kim, Wonjusi, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseGeun Young Park, WonJu, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseChaeeun Jung, Wonju, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseEunsup So, WonJu, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseYong J. Kim, Wonju-Si, Korea, Republic Of (Abstract Co-Author) Nothing to DiscloseHee-Joung Kim, PhD, Seoul, Korea, Republic Of (Abstract Co-Author) Nothing to Disclose

PURPOSE

3D printing is a rapidly evolving technology that allows the fabrication of complex three dimensional and multi-material objects foranatomic models, medical tools, and even quality control (QC) phantoms. The design and QC performance analysis of 3D phantomfor multi-modality system has not been investigated rigorously. The QC phantom can be easily fabricated with complicate shapes byusing 3D printing technology. The goal of this work was to design pre-clinical or clinical QC phantom and validate its performancefor multi-modality system.


For design of the phantom, the SOLIDWORKS 2012 Computer Aided Design (CAD) software was considered due to the flexibility ofapplications. The model was exported in mesh format (.STL) for 3D printing and a multi-material printer (Objet Eden, Stratasys Ltd.)was used. The prototype phantom was composed of 3 main parts to support both X-ray imaging and nuclear imaging. For nuclearimaging, phantom was designed to evaluate the image quality, including spatial resolutions and uniformity, in accordance with theNEMA NU-4 2008 protocols. For X-ray imaging, we developed 8 containers to be filled with dilutions containing 0.1% to 1.0% ofcontrast agent and high- and low contrast resolution disk and uniformity area.

RESULTS

For the purpose of comparison with the NEMA NU 4-2008 image quality phantom, we considered mainly the uniformity and thespillover ratio. Indeed, the developed phantom resulted in very good qualities. Moreover, for X-ray imaging, preliminary analysisrevealed consistent HU linearity with increasing iodine concentration and shows a high spatial resolution of up to 1.5 mm.

CONCLUSION

The results indicated that developing a complicate QC phantom can be designed to evaluate the systems for multi-modality imagingsimultaneously. Our phantom has flexibility of changing quality parameters for the multi-modality system by changing the QC disk ina standard manner.


The proposed QC phantom can be used for variety of pre-clinical or clinical applications in multi-modality system, SPECT/CT,PET/CT, Spectral-CT, simultaneously.