1. Highlights on the Workshop on Radiation Protection in Paediatric Imaging held on 9 – 13 November 2015 Pr B MANSOURI Cairo Egypt 13-16 Dec 2015 Regional Workshop on Imaging Referral Guidelines IAEA TC-RAF/9/053

2. Organized by :  The International Atomic Energy Agency (IAEA) in cooperation with the Government of Kenya through the Kenyatta National Hospital 28 Participants 19 countries Attended by :

3. Specialties  Radiologists  Surgeons  Medical physicists  Technologists/Radiographers  Regulators

4. Scientific Programme  5 day course (2 days ‘justification’ and 3 days ‘optimization’)  29 lectures (Many presentations have been both in English and in French (Break out by language ))  The Radiation Safety Culture: Image Gently  Global Perspective on Radiation Protection in Paediatric Imaging (DR and NM)  International BSS the Role of Government and Medical Professionals in Radiation Protection  Introduction to Justification  Adoption and Adaption of Diagnostics Imaging Guidelines for Paediatric Populations  Development & Implementation of Paediatric Diagnostic Imaging Guidelines in Africa  Acceptance and Use of Clinical Imaging Guidelines by Referring Medical Practitioners  What is Optimization and what can we do to reduce patient dose in imaging  Establishing protocols for measurements  Exercises in measuring exposure and estimating patient dose for radiography and CT  How do we develop the facility and national diagnostic reference levels  Exercise at the Hospital on measuring exposure and calculated estimated dose imaging (for radiography and CT)  Implementation of activities to reduce radiation exposure to the paediatric patient  Country action plans on Guidelines and Optimization of Paediatric Imaging.  (All participants) Justification Optimisation

5. The Radiation Safety Culture: Image Gently Kimberly E. Applegate, USA  Building Safety Culture  Lack of RP Knowledge  Sharing of Knowledge, Lifelong Learning  Solutions (examples):  Image Gently Campaign  WFPI  [Image Wisely and EuroSafe Campaigns]

6. Global Perspective on Radiation Protection in Paediatric Imaging Maria del Rosario Perez, WHO  Health service delivery is one of the building blocks of health systems.  Good health services are those which deliver safe and effective health interventions to those that need them, when and where needed, with minimum waste of resources.  Radiation safety in medicine is embedded in health care quality and health systems strengthening.

7. Radiation Protection in health care risks benefits.  To control and minimize health risks, while maximizing the benefits.  Achieving this balance becomes particularly challenging in medicine. paediatric patients  This is PARTICULARLY IMPORTANT in paediatric patients. Maria del Rosario Perez, WHO

8.  Clinical context, medical history  Defensive medicine  Knowledge about procedure – benefits, risks, limitations  Financial conflict of interest Referral guidelines / criteria of appropriateness..shall be carried out through consultation between the radiological medical practitioner and the referring medical practitioner, …. Refereeing physicians Radiological practitioner “Request for consultation” versus “order/instruction to perform” International BSS the Role of Government and Medical Professionals in RP D. Gilley, IAEA

9. A basis for strengthening the implementation of justification  Joint responsibility  Development of referral guidelines or appropriateness criteria  Professional bodies  Use of referral guidelines or appropriateness criteria  Software for referral  Availability of relevant information from the patient’s previous radiological procedures  Not new, but increasingly realisable Information technology, hardware & software will provide tools to help with the implementation of justification. Availability and Use of Appropriateness Criteria is pivotal. D. Gilley, IAEA

10.  Registrants and licensees and radiological medical practitioners shall ensure that protection and safety is optimized for each medical exposure Components to consider: Design considerations Operational considerations Calibration Patient dosimetry DRLs QA Dose constraints Requirement 38: Optimization of protection & safety D. Gilley, IAEA

11. Causes of inappropriate imaging  Insufficient risk awareness, arising from insufficient risk assessment  Absence of referral guidelines  Lack of a radiation safety culture  Resorting to imaging as means of diagnosis & as a substitute to thorough clinical assessment  Self-referral  Self –presentation  Litigation pressure  Unnecessary information void between referrers, and radiologists, radiographers & patients.  M. Kawooya, Uganda

12. Justification and referral guidelines M. Kawooya, Uganda

13. Africa Specific Diagnostic Imaging Guidelines in Paediatric Imaging  Most african countries have a poorly performing health system.  The economic and financial difficulties of the States and poverty keep the country in a pronounced delay in terms of medical technology.  Africa with only 1.3% of health workers bears 25% of the global burden of disease.  Many hospitals use medical devices, often sent by international aid,  Many devices are useless, partly because of climatic conditions and instability of electricity networks.  The lack of qualified personnel or maintenancy ( avalaibility of spare parts ) disappear any hope of making them work.  In developing countries: Over 70% of donations resulting medical devices are never put into service.  Over 50% of the medical devices do not work or are not used properly!  Lack of access to medical imaging in general is a serious public health problem B. Mansouri, Algeria

14. Africa Second hand equipments? Human resources? Maintenance? Environment? Lack of paediatric radiologist Lack of understanding of the role & responsibilities of clinical medical physicists Lack of structured and competence- based clinical training in all pediatric field Lack of regulatory bodies Lack of guidelines and imaging appropriatness criteria Financial constraints for quality assurance programs B. Mansouri, Algeria

15. Providing a comprehensive approach for the development of paediatric imaging in the following areas:  Facility guidelines and personnel qualifications Facility guidelines and personnel qualifications  Education and communication Education and communication  Appropriate use Appropriate use  Equipment safety features Equipment safety features  Tracking radiation safety metrics Tracking radiation safety metrics  Research and development Research and development B. Mansouri, Algeria

16. Guideline Development The Right Exams, for the Right Reason, Done the Right Way K. Applegate/ B. Mansouri (Break out by language)  Review the ACR Appropriateness Criteria and their role in promoting appropriate utilization of imaging  Review specific Appropriateness Criteria and how they can be utilized in clinical practice  Discuss the similarities with the RCR Guidelines  Adaptation of national guidelines to local or regional use

17. Optimization of the dose in Imaging is the effort to get the best image quality possible at the lowest dose to reduce the risk of adverse biological effects (patients and staff). Once the procedure justified, it must be optimized to ensure that the clinical objective is achieved with minimal irradiation What is Optimization and what can we do to reduce patient dose in imaging N. Khelassi-Toutaoui, Algeria Optimization is usually applied at two levels: The design and construction of equipment and installations Day to day radiological practice (procedures)

18. N. Khelassi-Toutaoui, Algeria for each medical radiation facility: The principle of optimization of protection is being applied to every exposure : 1. Design considerations for equipment 2. Operational considerations 3. Calibration 4. Dosimetry of patients 5. Diagnostic Reference Levels (DRLs) 6. Quality assurance 7. Dose constraints

19. Benefits from patient dose measurements  Practice improvement  Evaluate clinical indicated imaging protocols, age and body parameters  Patient dose registry  Local DRLs-clinical indications  National DRLs-clinical indications 19 Establishing protocols for paediatric patient dose measurements G. Korir, USA

20. Increase availability of global information on medical and occupational exposures in medicine medical exposures  Improve collection of dose data and trends on medical exposures globally, and especially in low- and middle-income countries, by fostering international co-operation; occupational exposures in medicine  Improve data collection on occupational exposures in medicine globally, also focusing on corresponding radiation protection measures taken in practice;  Make the data available as a tool for quality management and for trend analysis, decision making and resource allocation. G. Korir, USA

21. Exercises in measuring exposure in radiography and CT and estimating patient dose / Peadiatric patient (with practical sessions/hospital) N. Khelassi / G. Korir (Break out by language) In Radiography Dose parameters in general radiography Use of phantoms in patient dose assessment Use of indirect method in patient dose assessment Use of direct method in patient dose assessment Examples of patient dose assessment

22. Exercises in measuring exposure in radiography and CT and estimating patient dose / Peadiatric patient (with practical sessions /hospital) In CT Metrics used for in C T dose Phantom measurements DLP and effective dose Examples o Measuring CT air kerma index o Measurement of C PMMA,100, c and C PMMA,100,p using the standard head and body phantoms; calculation of C W o Calculation of the CT air kerma–length product, for abdomen examination Size Specific Dose Estimate (peadiatric) (SSDE) N. Khelassi / G. Korir (Break out by language)

23. Back to Basics CR/DR 2012 SEPTEMBER 2014 Dental Campaign www.imagegently.org Optimization in Paediatric Fluoroscopy Kimberly E. Applegate, USA

24. Optimization in Paediatric CT N. Khelassi-Toutaoui, Algeria General Recommendations  You must use paediatric protocols to reduce the dose for the same image quality as in adults  Make sure there are no inappropriate high (e.g. adult) parameter settings behind the name paediatric protocols  Plan paediatric scans according to patient’s size and age

25. Generic Requirements for Optimisation in CT  Inform and prepare the patient and accompanying person(s).  Be familiar with CT dose descriptors.  Realise lower noise usually means higher doses; accept noise if scan is diagnostic.  Optimize scan parameters within the axial plane.  Optimize a set of tube current settings for paediatric examinations.  Scan minimal length and minimise repeated scanning at identical areas. N. Khelassi-Toutaoui, Algeria

26. Possible problems and solutions Lack of peadiatric dose assessments Its too difficult even impossible Its not required Symptom Professionals Argument Sampling according to morphology Size of the samples too large (N=30) Peadiatric examinations are less frequent Possible solutions Focus of paediatric dedicated facilities Promote the use of dose management system Decrease the size sample (N=15 or 20) Establish DRLs as curves Incitation Obligation Communicate about exposure of children Use smaller samples size than adults Make mandatory dose assessments for peadiatric examinations Practical difficulties in data collection and analysis G. Korir, USA

27. How do we develop the facility and national diagnostic reference levels? N. Khelassi / G. Korir (Break out by language) The principle of optimization of protection is being applied to every exposure : 1. Design considerations for equipment 2. Operational considerations 3. Calibration 4. Dosimetry of patients 5. Diagnostic Reference Levels (DRLs) 6. Quality assurance 7. Dose constraints

28. DRLs Evaluer, du point de vue des doses délivrées aux patients, la qualité des équipements et des procédures - Examens les plus courants et/ou les plus irradiants - Patients types (adultes, pédiatriques (0-1, >5, >10, >15) - Fantômes de référence Engager, en cas de dépassement injustifié, des actions de contrôle et de correction. N. Khelassi / G. Korir (Break out by language) How do we develop the facility and national diagnostic reference levels?

29. Implementation of activities to reduce radiation exposure to the peadiatric patient Maria del Rosario Perez, WHO XXI century RP in paediatric healthcare seen as a priority Image Gently campaign IAEA International Action Plan on Radiation Protection of Patients WHO Global Initiative on Radiation Safety in Health Care Settings ICRP, EC, others…

30. Maria del Rosario Perez, WHO Health authorities, health care providers (radiologists, medical physicists, radiographers), manufacturers, and patients' representatives 4 Member States and 9 NGOs in Official Relations with WHO

31. Developing Country specific plans for clinical Guidelines and protocols for measuring Radiation dose in Paediatric Imaging (All participants) Participants have presented their specific action plan concerning Clinical guidelines Dosimetric protocols