ICRP – Consultation
‘Optimisation of Radiological Protection in Digital Radiology Techniques for Medical Imaging’ – Draft document for comments
Comments and Feedback from the ISRRT
Author: A Stewart Whitley 22.9.2022
General Comments
The ISRRT is pleased to comment and provide feedback for this excellent draft document which contains a lot of useful and well written content. We like the part on education and need for CPD.
We are particularly pleased and support and welcome the concept of a team approach as radiologists, medical physicist and radiographers/radiological technologists working together have a lot of shared knowledge and experience in dose optimisation.
However, we need to be mindful with the narrative in some places when phrases such ‘radiographers can also perform’ and ‘medical physicists supervising radiographers’ this could be seen as minimising the radiographers’ position suggesting to the readers that radiographers are not to be trusted for such tasks.
Instead of saying ‘under supervision of a qualified medical physicist’ say something like ‘if required should be undertaken with the guidance and advice of a qualified medial physicist’. – we don’t want to give the impression of a hierarchical structure
In many situations radiographers carry out IPEM Report 91 Level A tests without supervision.
In Japan, Medical physicists are rarely active in the diagnostic field. Therefore, it should be clearly stated that radiographers/radiological technologists are responsible for quality control in the diagnostic field in such countries.
There are many terms used to describe the radiography profession across the globe i.e., Asia and the USA ‘radiological technologist’, Europe ‘radiographer’, Canada ‘medical radiation technologist’ and Australia ‘medical imaging technologist’. The ISRRT has agreed an appropriate definition ‘Radiographer/Radiological Technologist’ to be used by international organisations. (https://www.isrrt.org/pdf/ISRRT_radiographer_definition.pdf). Therefore, terms such as ‘technician’ should be deleted or replaced the term ‘radiological technologist’
We would also like some reference to training on the use of accessories and other devices such as contrast injectors which may affect image acquisition and contribute to image quality.
The radiographer’s role in justification process should me more emphasised, although we like that the term ‘radiological practitioners’ is used, and that when reading it understand that this also includes radiographers in that group in this section of the document.
We were a bit disappointed that there was inadequate mention of the radiographer's potential role in adjusting/choosing protocol for individual patient's when necessary, working with non-radiologic members of the healthcare team, and their responsibility for educating themselves.
ISRRT response to specific lines
Lines 150-153 – feedback suggests that the specific method of quality control that the key points in this section has not been introduced in many hospitals in Japan and will take time to implement.
Line 224 – in the UK reporting radiographers may be the only radiological team members to see such images. Perhaps a re-phrase is needed to broaden this fact.
Line 227/228 – radiographers are taught the physical principles behind image formation and can perform and interpret measurements of dose and image quality up to a certain level as per regular QA programs
Lines 233- 237 – Fully agree
Line 251-252 - as low as practicable – could we say ‘as low as reasonably practicable’
What about mentioning the role of ‘Reject Rate analysis’ and ‘standardised exposure index for digital radiography’ in optimisation
Lines 263-264 – radiographers also play an important part in evaluation of image quality as part of a robust reject analysis programme which also extends to regular use of QC test tools
Line 274- 275 – ‘there need to be management systems’ – perhaps ‘there needs to be management systems’
Line 291 ‘benefits and harm on both indication and patient levels.’ - perhaps ‘benefits and harm on both clinicalindication and patient levels.’
Line 297-298 – agree
Line 301 - ‘Practical aspects that depend on specific x-ray techniques’ – perhaps ‘Practical aspects that depend on specific x-ray image acquisition techniques’
Line 311 – perhaps in addition to mentioning CT equipment maybe we should also give an example of complex C-arm fluoroscopy equipment used for cardiac/angiography procedures.
Note: whist recognising that CT is based on digital technology the move from film/screen technology to digital x-ray image acquisition should be more emphasised.
Line 313-314 – ‘requires radiologists, radiographers and medical physicists with high levels of expertise, working together as a team’ suggest that this changes to ‘requires radiologists, radiographers and medical physicists with high levels of expertise, working together as a team and applying key agreed Knowledge, skills and competencies’
Line 382 – ‘can use reference levels as a guide.’ – perhaps ‘ can use reference dose levels as a guide.’
Line 413-417 perhaps we should also mention tools like ’eject analysis’ which can be provided by manufacturers as optional softer on digital x-ay (DDR) equipment.
Line 429 -430 – could also mention AP verses PA
LINE 529 ‘radiology professionals’ – need to define what is meant by this term as it is mostly radiographers on a day to day basis applying these skills
Line 531 – ‘depending on their size and weight.’ – perhaps depending on their size, shape, and weight.’
Line 533 – ‘shielding for the gonads is no longer considered appropriate’ – whilst this in the main is accepted there may be circumstances when it is necessary for follow up procedures and applied by skilled operators why not say ‘shielding for the gonads is generally no longer considered appropriate’
Line 554 (radiologist) – this should apply to anyone viewing the image who must record a comment (IRMER) – perhaps (radiologist/reporting clinician) – many examples when images are not reported by a radiologist
Line 562 ‘knowledge from clinicians, skill from the operators’ what is meant by clinicians – do we mean referring clinicians? Additionally, we would prefer to have the word operators changed to radiographers
Line 726 – • Ongoing monitoring, review, and analysis of performance feeding into continuing improvement in every aspect of the imaging process - I would like mention of ‘image reject analysis’ in this section as this should form part of the training programme and audit
Line 743 – 744 - ‘that clinical protocols are established’ – perhaps ‘that clinical protocols are established and modified’
Line 763- 778 – I would like to have mention of ‘accessories’ such as ‘contrast injectors’ used in CT and angiography as these play and important and integral part in acquiring images of the desired image quality. If not here they must be mentioned as staff need to be trained in their use – they also have a life cycle.
Lines 784-785 ‘ the team need to prepare a technical specification based on the clinical requirements’ – perhaps ‘The team need to prepare a technical and operational specifications based on the clinical requirements’
Line 785 – the team should also agree an evaluation/scoring system to select the equipment that meets their needs – this is part of the procurement process
Line 786 – ‘the major system components, any accessories that might be required’ – I would like to suggest that we add reference to basic quality control test objects which radiographers can use as part of their QA programme. Best to purchase this at this stage.
Line794 & 801 – ‘appropriate acquisition’ – perhaps ‘ appropriate procurement’ - procurement is a better term as it describes a process
Line 808 – acquisition v procurement – possible word change
Line 829 – ‘radiographers / imaging technologists’ – would prefer ‘radiological technologists’ - we want to get the message across that we want professionally trained staff operating equipment
Line 845 – ‘Tender, evaluation and acquisition’ – this process usually starts with the first step of issuing as ‘Expressions of interest’ notice to vendors though a general advert or wring to a list of vendors. This is an important step in the process and makes the next step more manageable. At this stage the operational specification can be issued so that vendors know what to expect in terms of the nature of the work being undertaken.
I would change the term ‘acquisition’ to ‘procurement’
Line 856 – change acquisition to ‘purchase order’
Line 861 – ‘Enabling and installation’ – change to ‘Enabling and installation works’
Line 874 – ‘..inventory and probably performing electrical…’ delete ‘probably’ this is part of the acceptance process – certainly in the UK
Line 885 – prefer procurement to acquisition
Line 936 - 936 - Understand the importance of reporting device-related adverse incidents – please add the use of a a faults book linked to the equipment which should include details of faults and when they were fixed.
Line 947 ‘imaging technologists’ – change to ‘radiological technologists’ – we do not recognise this group, we want to get the message across that we want professionally trained staff operating equipment
Line 948 ‘A medical physicist, or in some cases a senior radiographer,’ delete ‘in some cases’ – from experience it is impracticable to have a medial physicist. A QA committee should be set up involving radiographers trained in QC tests and meeting regularly.
Line 959-961 – ‘Some QC measurements may be undertaken by radiographers’ - this seems to denigrate the capability of radiographers. From my experience QC test that are required, as part of an agreed QC programme, were conducted my experience degree qualified radiographers when no medical physicist was available. Perhaps the sentence can be reworded. Instead of saying ‘under supervision of a qualified medical physicist’ say something like ‘if required should be undertaken with the guidance and advice of a qualified medial physicist’. – we don’t want to give the impression of a hierarchical structure
Line 979 – ‘radiographers / imaging technologists’ – as above – delete ‘imaging technologists’ or replace with ‘radiological technologists’
Line 989 - test objects (IPEM’ – do you mean IPEM 91? Or its eventual replacement
Line 1021 -1022 – ‘All medical imaging equipment must be maintained appropriately. Often equipment 1022 comes with a limited warranty providing maintenance to vendors’ specifications for a set time.’ – perhaps mention that in addition to this traditional model there are other arrangements such as whereby equipment purchased in part of a comprehensive supply and ongoing maintenance and repair arrangement for a set period of time i.e., ‘managed service contact’.
Line 1033 - radiographer / imaging technologist – again remove ‘imaging technologist’ or replace it as indicated previously
Line 1037 – ‘under supervision of a medical physicist’ – suggest remove this and say ‘as per agreed protocols’ - it is not practicable for a medical physicist to be present in most hospitals – in collaboration yes. Or change to ‘advise and assist if appropriate.’
Line 1042 – ‘a lease has expired’ – could add ‘a lease or managed service contract has expired’
Line 1095-1099 – Fully agree – need to be careful with language which does not undermine this objective
Line 1118 – ‘multi-professional expertise’ – alternatively just ‘professional expertise’
Line 1244 – ‘the radiologist is essential for appropriate justification’ – perhaps we can use the term ‘radiology practitioner’ or a more neutral term here – radiographers are also in charge of consulting and justification
Line 1252 ‘, images are evaluated by radiologists and clinicians,’- in many countries radiographers evaluate images as part of their image acquisition process including reporting radiographers
Line 1320 – mention kV also? – linked to patent thickness
Line 1341 – A – Advanced – ‘System to determine acceptable exposure based on requirements’ – perhaps change to ‘System to determine acceptable exposure parameters based on requirements’
Line 1378 – ‘train radiological staff in radiological imaging science,’ – is this training to undertake optimisation/QC test or to train as radiographers?
Line 1599 – FID – in Clark’s Positioning in Radiography 13th edition we use ‘FRD’ for focus to image receptor distance
Line 1640-1741 – is it worth mentioning he fact that some DDR units have in built software to enable all exams performed dose parameters to be extracted and compared – assisting with local DRL calculation. Guess this get more complicated when calculation the local DRL across a range of x-ray rooms.
Line 1664 – I guess CR = ‘Computed Radiography’?
Line 1716 and elsewhere – ‘uncertainty budget’ – need to explain what this is as this may be an unfamiliar term
Line 1741 – DRLs (local) – are we talking about specific examinations from all x-ray rooms in a facility or an individual room
Line 1885-1886 – ‘interpreter who reviews’ – increasingly other clinicians and reporting radiographers undertake this task
Line 1904 – why include ‘technicians’ – please delete or use the term ‘radiological technologist’
Line 1914 – ‘doctor’- is just one example who may be evaluating an image – do you what to expand this to include other healthcare professionals who also may be an observers?
Line 1926 – ‘radiologist’ – see comment above - lines 1885-1886
Line 1933-1934 – radiographers can also play a role phantom image analysis
Line 2260 – ‘primarily radiologists’ – suggest delete as the beginning of the sentence is sufficient or change to ‘‘primarily radiologists and reporting professionals’ – this is to reflect the fact that there are many other professionals reporting.
Line 2263 – ‘technologist’ – delete or replace with ‘radiological technologist’
Line 2264 – ‘when required’ – maybe change to ‘when and if required’ - this is to reflect the fact in some instances when undertaking daily routine QA on some CT scanners as part of the arm up procedure the radiographer may have to contact the vendor directly to remedy the situation.
Line 2271 – same point as in line 2264
Line 2268 – ‘radiologist image review’ – change to ‘radiologist and professional reporter image review’ reflecting that fact that not all images are reported by radiologists but all who do have this responsibility.
Line 2299 – chest PA – no anatomical marker shown and collimation too tight on the left side – looks like post processing collimation applied – not the original image
Line 2300 – ‘Fig. 5.8 An example x-ray chest PA projection produced …’ – change to ‘Fig. 5.8 An example x-ray chest PA projection image produced ...’
Line 2328 – remove ‘technicians’ or replace with ‘radiological technologists’
Line 2333 – include ‘reporting professionals’
Line 2366 - 5.4.2. Role of display monitors and their performance in the image quality chain.
I think mentioning the various types of monitors would be useful and eliminate any confusion.
The TG18 report defined two display classes: primary displays were those used for interpretation of medical images, while secondary sdisplays included all other displays used in medicine. This report further categorizes secondary displays based on their use, with varying requirements for performance and evaluation. In this report, all displays used in the review of medical images are separated into the following categories:
1. Diagnostic displays
2. Modality displays
3. Clinical specialist displays
Bevins NB, Silosky MS, Badano A, Marsh RM, Flynn MJ, Walz-Flannigan AI. Practical application of AAPM Report 270 in display quality assurance: A report of Task Group 270. Medical Physics. 2020;47(9):e920-e928. doi:10.1002/mp.14227
Line 2475-2478 – this task is often undertaken by experienced radiographers, especially when there is no medial physicist support. What about ‘medical physicists, along with radiographers and radiologists, have a key role in optimisation ensuring a link between ….’
Line 2543 – ‘radiographer/technologist’ – change to ‘radiographer’ or ‘radiographer/radiological technologist’
Line 2558 – Referring Physician – perhaps add ‘provide details of previous imaging studies’
Line 2694 – should ‘physicians’ not be ‘radiologists’? Radiologists are not mentioned.
Line 2753 – ISRRT, as a professional society, has resources and training materials available on their website
Line 3413 – suggest ‘radiologists/reporting professionals’
Line 3445 – ‘clinical image quality be radiologists’ – typo ‘be’ – ‘by’. Suggest ass reporting professionals as radiologist may not be involved in certain situations i.e. cardiology & GI
Line 3474-3475 – ‘Examples of KSCs required for optimisation of x-ray imaging 3475 procedures’ – excellent list that does not differ between the professions. Perhaps when referring to KSCs in the main document this annex should be referenced when mentioning who does QC tasks.
A S Whitley
ISRRT Director of Professional Practice – 22.9.2022s