Monitoring Pediatric CT Dose at Adult Hospitals

With proper protocols in place, a child would get a similar amount of radiation from a CT scan regardless of which hospital the test was performed, right? Not necessarily.

Children undergoing an abdominal or pelvic CT got a far lower dose in a dedicated children’s hospital versus the same institution’s affiliated adult hospital, according to a study published in the May, 2012 Journal of the American College of Radiology. In all eight weight groups but one, the effective radiation dose was significantly decreased in the pediatric hospital, according to researchers who compared 495 pediatric scans performed at an adult hospital and 244 from a children’s hospital.

“I was surprised when I saw the difference in improvement with the abdominal and pelvic CT (radiation dose),” said Heather Borders, MD, lead author and pediatric radiologist at the Spectrum Health Helen DeVos Children’s Hospital in Grand Rapids, Mich.

This dramatic difference between the adult and children’s hospital doses is because the children’s hospital only uses dedicated pediatric technologists for the scans, and they’re following the protocols closely, Borders said. At the adult hospital, the compliance rate for using the pediatric protocols was low - 21 percent to 44 percent. (They did not break down the compliance rate by individual technologists or technologist specialty.)

For those scans with a low compliance rate, “the pediatric patients were being scanned with the adult protocol, just adjusted a little,” she said. While the pediatric protocols were available at Spectrum Health Butterworth Hospital, many of the technologists weren’t following them.

According to Keith Strauss, clinical pediatric imaging physicist at Cincinnati Children’s Hospital Medical Center, one reason radiation doses are lower with pediatric specialists is because they do a better job at what they do the most. “If a group of individuals continually and constantly work with children, they’re going to develop better techniques, methods and abilities than another institution that only images children on a part time basis,” he said.

Monitoring the technicians to make sure they’re following protocols is important in both pediatric and adult hospitals, said Borders.

Using pediatric technologists for kids in a mostly adult hospital is helpful, but when they’re not available, and no one is monitoring the scans, the dose can be unreasonable.

“We had a couple of pediatric-specific technologists [at the adult hospital] but they worked the day shifts,” said Borders. “They assumed the protocols were being followed [by other technicians] but never monitored them. You have to check on that and monitor the dose and make sure the compliance is as high as you anticipate. I don’t mean to say ‘don’t scan kids in adult hospitals.’ If you are going to do that, you have to be more diligent about following your technicians and make sure they’re doing their job.”

With only about 40 standalone pediatric hospitals in the country, most pediatric CT scans will be done in an adult hospital, Strauss said.

“Hospitals believe if you have one or two pediatric specialists, that their expertise will rub off on everybody,” he said. “That’s not as successful as people hope. These specialists may not get the support they need to be really successful.”

To successfully lower the pediatric radiation dose in an adult hospital, “you’ve got to have some champions to promote the cause, and you have to give your totally committed support,” Strauss said. “When a subgroup of patients that you’re treating is quite small, when you see that small cohort demanding a non-representative piece of the overall budget and resources, the necessary support may not be available.”

What can adult hospitals do?

For hospitals that treat pediatric patients in addition to adults, all is not lost in terms of giving the lowest effective radiation dose possible. But it will require work.

Strauss recommended that hospital or radiology personnel consult the Image Gently website, which provides “adult institutions that want to do a better job with pediatric patients some starting points,” he said. It does require, however, that the institution engages its technologists, physicists and radiologists to work together as a team to develop pediatric-specific protocols and approaches to pediatric imaging. “You can’t make a decision and devote two hours to it and be done. It’s a continual process,” Strauss said.

Borders agreed. “It’s important to have a system in place to monitor the doses. In our department, we have a quality and safety person, and she was recently hired and started taking control of that monitoring process,” she said. “There needs to be a radiologist involved who is interested and pushing things along. It needs to be a combined effort. We do it as part of our ALARA committee. We include the CT technicians, a radiologist, physicist and quality and safety person.”

And hospitals have come a long way, Strauss said.

“Some adult institutions today are doing a better job with pediatric patients. There’s more information, they’re aware of work that’s been done in pediatric hospitals,” he said. Ten years ago very few people realized that you needed pediatric-specific protocols for CT in children, he added. “Now it’s understood and they know there’s a need for that, and many have made an attempt to do that. Maybe their attempts are not as aggressive as they should be, but they’re doing something. Pediatric doses have improved.”

The FDA recently released a draft proposal suggesting that manufacturers develop new protocols and instructions for use on pediatric patients, providing this for premarket notifications. The FDA scheduled a workshop on July 16 to seek opinions from industry, radiologic technologists, physicists, physicians and patient advocates.

Borders said that the FDA proposal is “a great idea if it’s easier to pick the pediatric protocol. Anything they can do to improve compliance in pediatric protocols, anything to make it more streamlined and easier to follow.”