Download Safe Pediatric Imaging: Intro - Children`s Hospital Association

Safe Pediatric Imaging: Intro
James R Duncan, MD, PhD
St. Louis Children’s Hospital
Disclosures
•
Scientific Advisor: Proteon, Metaactive, Flow Forward
•
•
Board of Directors
•
•
Former graduate student with/ three startups investigating drugs and
products for dialysis access and vascular interventions
American Board of
Radiology Foundation
Father with 3 sons
2
Common Scenario
Your child
Falls at the playground
Huge visible contusion
Screaming uncontrollably
What would do you do?
As a father who happened to be a radiologist, I drove frantically to the
ER because my mental model is: “Jonathan needs an urgent head CT”
St Louis Children’s Hospital ER
Recommended watch and wait
How Do We Improve Imaging?
Imaging provides tremendous benefit
Clear utility, life-saving technology
However “too much of a good thing” is overuse
Imaging
Antibiotics
Extra studies per illness
Antibiotics for viral infection
Extra images per study
2-4 drugs when 1 is enough
Extra dose per image
Adult doses given to children
Need to eliminate such overuse
Preserve the benefits while reducing the risks
Overuse: Extra Studies per Illness
• Extra studies occur during routine
care of common conditions
•
Minor head trauma
• Each year many of our youngest
children visit the ER for head trauma
• Most do not need a head CT
•
Abdominal pain
• Not every child needs an imaging study
• Also, ultrasound can often be the first
imaging study
Source: Centers for Disease Control
Overuse: Extra Images per Study
An example is “dual scans”, CTs done without then with IV contrast
Double the radiation exposure, extra cost, little if any additional value
Overuse: Extra Dose per Image
Scanner settings often
not adjusted to match
the clinical need or
child’s size
Earth Rise Apollo 8
5x5 pixels
.03K
75x75 4K
12/24/1968
9x9 pixels
.08K
18x18 pixels
.24K
37x37 pixels
1.0K
150x150 16K
300x300 64K
600x600 256K
Meet Morgan*
11yr old girl with RLQ pain, R/O appy
CT abdomen and pelvis (instead of US)
3.7mm noncalcified nodule
“unknown malignant potential … recommend follow-up CT without & with contrast”
Follow-up Chest CT
3.7mm noncalcified nodule, recommend further follow-up
Referred to Interv Radiology for possible needle biopsy
*Not her
real name
Aug 2013
Sept 2013
Overuse Adds Up
Rule out appendicitis example
Studies per illness that use Xray
1 US vs 3 CT scans (1 abd/pelvis CT, 2 chest CTs)
Images per study
Limited single phase Chest CT vs without and with of the entire chest
Dose per study
Pediatric vs adult CT settings
Same outcome: 0 vs 25 mSv
Annual limit for nuclear plant workers (50 mSv)
25 mSv has an estimated future cancer risk of 1 in 400
Three Presentations
Children’s Hospitals – reducing CT utilization
Fewer scans for common conditions
Washington State Hospital Association
Statewide dissemination of best practices
St. Louis Children’s Hospital
Using data to drive improvement in a hospital network
Plus: Joint Commission is Proposing a Safe Pediatric
CT as a 2017 National Patient Safety Goal
11
Decreased Computed Tomography and
Shifts to Alternate Imaging Modalities in
Hospitalized Children
Michelle Parker MD1, Samir S. Shah MD, MSCE1, Matthew Hall PhD2, Evan S.
Fieldston MD, MBA, MSHP3, Brian D. Coley MD1, Rustin B. Morse MD, MMM4
1Cincinnati
Children’s Hospital Medical Center, Cincinnati OH; 2Children’s Hospital Association, Overland
Park, KS; 3Children’s Hospital of Philadelphia, Philadelphia PA; 4UT Southwestern, Dallas, TX
Disclosures
Michelle Parker has documented no financial
relationships to disclose or Conflicts of Interest to
resolve
Michelle Parker has documented this presentation will
not involve discussion of unapproved or off-label,
experimental or investigational use
Background
Computed tomography (CT) scanning is a major source of
ionizing radiation for patients in the hospital
Children are more susceptible to ionizing radiation
Doses administered by CT scans associated with 1
additional cancer per 10,000 children exposed
National efforts have focused on minimizing the radiation
dosage per scan and frequency of CT utilization in children
Mathews JD. BMJ. 2013.
Background
Frequency of CT utilization in children during past 2
decades initially increased dramatically
Plateau as early as 2006, followed by a decline
Unclear whether the declines are a result of decrease in
overall imaging or a shift to alternate imaging modalities
Mathews JD. BMJ. 2013.
Objectives
To assess trends in CT utilization in hospitalized
children
To determine if changes are associated with shifts to
alternate imaging modalities
Methods and Analysis
Study Design: Multicenter cross-sectional study
Data Source: Pediatric Health Information System (PHIS)
33 children’s hospitals, 2004 - 2012
Comprehensive database of administrative and financial
data from contributing children’s hospitals including
demographic data, diagnosis codes, and items/services
billed to the patient
Methods and Analysis
Inclusion: Patient discharged with any one of the 10 most
common All Patient Refined-Diagnosis Related Groups
(APR-DRGs) for which CT was performed in 2004
Utilization of CT, ultrasound (US) and magnetic resonance
imaging (MRI) for 10 most common APR-DRGs
Exclusion: Imaging codes not directly related to the final
applied diagnostic group as determined by 2 independent
reviewers, very low frequency codes
Methods and Analysis
Percentage of imaging utilization was followed
through the study period and assessed by
Cochrane Armitage trend test
Adjusted odds ratios compare the odds of imaging
in 2012 versus 2004
Demographics
N
Age, years
Male
Race
Insurance
a. <1
b. 1-5
c. 6-12
d. >12
a. Non-Hisp White
b. Non-Hisp Black
c. Hispanic
d. Asian
e. Other
a. Government
b. Private
c. Other
Total
152178
28392 (18.7)
52895 (34.8)
42180 (27.7)
28711 (18.9)
85195 (56)
76882 (50.5)
27882 (18.3)
26803 (17.6)
2669 (1.8)
17942 (11.8)
76467 (50.2)
56761 (37.3)
18950 (12.5)
2004
66433
13463 (20.3)
23913 (36)
17598 (26.5)
11459 (17.2)
37236 (56.1)
33584 (50.6)
12884 (19.4)
11421 (17.2)
1066 (1.6)
7478 (11.3)
27755 (41.8)
23932 (36)
14746 (22.2)
2012
85745
14929 (17.4)
28982 (33.8)
24582 (28.7)
17252 (20.1)
47959 (56)
43298 (50.5)
14998 (17.5)
15382 (17.9)
1603 (1.9)
10464 (12.2)
48712 (56.8)
32829 (38.3)
4204 (4.9)
Table 1. Demographics. 2004-2012 Inpt + Observation. Included 33 hospitals with data for all years. Top 10 APR-DRGs
p
<.001
0.69358
<.001
<.001
Demographics
Disposition
a. HHS
b. Home
c. Other
d. Skilled
Complex chronic
condition
ICU
Mechanical
ventilation
Length of stay, days
CMI (Charge Weight)
a. 0-1
b. 2-4
c. 5-7
d. >7
Total
1608 (1.1)
146459 (96.2)
3489 (2.3)
622 (0.4)
2004
609 (0.9)
64994 (97.8)
520 (0.8)
310 (0.5)
2012
999 (1.2)
81465 (95)
2969 (3.5)
312 (0.4)
p
<.001
57055 (37.5)
22054 (33.2)
35001 (40.8)
0.0567
18541 (12.2)
9122 (13.7)
9419 (11)
<.001
6780 (4.5)
3307 (5)
3473 (4.1)
<.001
71610 (47.1)
59630 (39.2)
11318 (7.4)
9620 (6.3)
29054 (43.7)
27390 (41.2)
5272 (7.9)
4717 (7.1)
42556 (49.6)
32240 (37.6)
6046 (7.1)
4903 (5.7)
<.001
0.92 (0.69-1.57)
0.90 (0.55-1.57)
0.97 (0.69-1.57)
<.001
Table 1. Demographics. 2004-2012 Inpt + Observation. Included 33 hospitals with data for all years. Top 10 APR-DRGs
10 Most Common APR-DRGs associated with
CT in 2004
1.
2.
3.
4.
5.
Seizure
Ventricular shunt procedures
Appendectomy
Craniotomy except for trauma, “Craniotomy”
Concussion, closed skull fracture, uncomplicated intracranial injury, coma
<1 hr or no coma, “Concussion”
6. Head trauma with coma >1 hr or hemorrhage, “Severe head trauma”
7. Infections of upper respiratory tract
8. Non-bacterial gastroenteritis with nausea and vomiting, “Gastroenteritis”
9. Abdominal pain
10. Other ear, nose, mouth, throat & craniofacial diagnoses, “ENT conditions”
Unadjusted Imaging Volumes
2004
CT Volume Rank. APR-DRG
1. Seizure
2. Ventricular shunt procedures
3. Appendectomy
4. Craniotomy except for trauma
5. Concussion
6. Severe head trauma
7. Infections of upper respiratory tract
8. Gastroenteritis
9. Abdominal pain
10. Other ear, nose, mouth, throat & cranial/facial diagnoses
Imaging
Modality
CT
MRI
CT
US
MRI
CT
US
CT
US
MRI
CT
MRI
CT
MRI
CT
CT
US
CT
US
MRI
CT
US
MRI
APR-DRG
Volume
16053
4446
7926
4094
2855
1670
8133
14103
2818
4335
2012
% Imaged
24.8
23.0
72.0
7.8
7.5
36.9
22.7
59.0
6.9
48.3
75.7
2.7
87.6
11.2
11.8
4.7
5.9
37.7
32.3
0.4
24.4
0.6
4.2
APR-DRG
Volume
23455
3529
12669
4503
3150
2062
14364
12165
4612
5170
Delta %
Imaged
% Imaged
13.3
20.3
64.9
11.0
22.8
23.4
44.5
51.4
7.9
58.6
62.8
4.2
70.2
15.9
7.5
5.0
17.3
25.6
51.0
2.0
18.1
1.4
4.1
-14.2
11.4
8.3
3.7
-11.4
-12.7
-4.3
11.7
8.2
-5.6
Imaging Utilization By Year
**
**
*
**
**
*
**
**
Figure 2. Trends in CT, US and MRI use for common APR-DRGs between 2004-2012. All trend test
p-values <0.001 except where denoted by *.
Modalities without data denoted by **
0.5 (0.5, 0.6)
Odds of Imaging
0.7 (0.7, 0.8)
0.6 (0.5, 0.6)
0.6 (0.6, 0.7)
0.6 (0.5, 0.6)
Severe head trauma
0.3 (0.3, 0.4)
0.6 (0.6, 0.7)
0.9 (0.8, 1.0)
0.6 (0.5, 0.7)
0.8 (0.7, 0.8)
Odds ratios adjusted for age, gender, race, insurance,
disposition, CCC, ICU, mechanical vent, length of stay, and
charge weight CMI.
1.5 (1.3, 1.8)
4 (3.5, 4.7)
3 (2.8, 3.2)
1.3 (1.2, 1.5)
1.9 (1.4, 2.6)
Severe head trauma
1.7 (1.4, 2.1)
3.5 (3.2, 3.9)
2.4 (2.1, 2.6)
4.7 (2.4, 9)
2.4 (1.5, 3.8)
Odds ratios adjusted for age, gender, race,
insurance, disposition, CCC, ICU, mechanical
Discussion
Decline likely multifactorial
• National collaboration targeting pediatric imaging to
raise awareness of the hazards of radiation
exposure and opportunity to use lower doses
• Published studies showing CT unnecessary
• National guidelines providing imaging
recommendations
• Technological advances
16
Limitations
Imaging patterns may differ in institutions not included
in the study
Imaging utilization from referring hospitals were not
captured
APR-DRGs reflect final diagnosis, not study indication
Administrative data may not fully account for interinstitutional variability in coding practices
Growing use of bedside ultrasound
Conclusions
Decrease in CT utilization with an increase in
ultrasound or MRI for 8 of 10 studied common
diagnostic groups.
Concerns of ionizing radiation may be influencing
providers’ choice
Physicians should be vigilant in choosing imaging
evaluations to maximize patient benefit while
minimizing financial and potential biological costs
Acknowledgements
Samir Shah MD, MSCE
Matt Hall PhD
Evan Fieldston MD
Brian Coley MD
Rustin Morse MD
http://www.chop.edu/health-resources/image-gently#.VroeYED8Qnk
http://www.chop.edu/news/children-s-hospitals-are-shifting-away-ct-use-other-imaging-tools#.Vroee0D8Qnk
http://www.chop.edu/news/lower-dose-safer-patients#.Vroej0D8Qnk
20
Safe Pediatric Imaging-Part 3
Washington State Hospital Association
Dave Wilson, MHA, RT(R)(CT)
Director of Safe Imaging Practices
March 8, 2016 - 0930
Washington State Safe Imaging Campaign
• Partnership for Patients
• CMS – 2013 Leading Edge Advanced Practice Topics
(LEAPT) Initiative
• Improving care in 17 areas, which are important to
clinicians and patients
• Safe Imaging – Concern for radiation safety
Starting Point
• Engagement of CEOs and Senior Leadership
• Foster engagement of radiology administrators and
directors
• WSHA organized monthly meetings with a cohort of 10
hospitals driving change in radiology
Goals and Objectives
• Engage radiology management, radiologists, and
technologists
• Build a collaborative environment between radiology
and the ED
• Establish outcome measures for data collection
• Share data and outcomes with quality leadership
• Set aside competition for collaboration
Pediatric Focus and Measurement
• The cohort of 10 hospitals chose to focus on pediatric
CT and radiation dose
• Dose Length Product (DLP) was chosen as the main
focus on the measurement of dose in CT
• A secondary measurement was established to focus on
single phase studies
• Providence Sacred Heart Medical Center and
Children’s Hospital led the effort
Strategies
Process
Measures
Participation
Ensure that Children Across
the State Receive Minimal
Radiation
Right Study
Observation for Minor Head
Trauma Using PECARN Tool
Provide Meaningful
Measurement for
Comparison
Right Order
Ultrasound First for
Suspected Appendicits
Provide Implementation
Resources and Best Practices
Right Way
Single Phase CT
Monthly Data Submission to
WSHA QBS
Provide Meaningful Reports
for Comparison
Right Action
Optimization of Radiation
Dose
Implement Strategies
Provide Implementation
Resources and Best Practices
Share Commitment to Using
Pediatric Protocols on
Organization's Website.
Provide Local and National
Experts
Share Information with
Quality Committees and
Board
Assist Organizations
Overcome Challenges
Right Report
Sign Up and Participate in
100K Children through
WSHA
WSHA Support
Attend Quarterly Meetings
WebEx/Calls
Safe Table
In-person
Lead WebEx Meetings
Optimization of Radiation Dose for
Pediatric Head CTs
• Numerator: Total Dose Length Product (DLP) for all
pediatrics head CTs performed in a month
• Denominator: Number of pediatric head CTs with
recorded DLP performed in a month
100K Children Campaign
• Collaborative efforts with Dr. Swenson and Dr. Duncan
the Washington State 100K Children Campaign was
initiated
• Data collected by WSHA was also utilized for the
National 100K Children campaign
• WSHA started spreading safe imaging to other
hospitals in the state.
Affordable Care Act
CMS Awards to Improve Health
Current Participations
• 26 Hospitals currently submitting data
• Actively engaging the other hospitals in the state
• Partnership for Patient data is distributed to senior
leaders each month
• Once a quarter WebEx's are presented by WSHA to
present data
• Twice a year in person meetings are held with local
and national experts speaking on safe imaging
Strategy Implementation
•
•
•
•
Reduce inappropriate studies
Reduce inappropriate orders
Reduce inappropriate techniques
Build a framework for ongoing success
Keys to Success
•
•
•
•
•
Right Study
•
Percent of pediatric patients receiving observation for minor head trauma
•
Percent of pediatric patients receiving ultrasound for suspected appendicitis
Right Order
•
Percent pediatric single phase head computed tomography (CT)
•
Percent of single phase chest computed tomography (CT)
Right Way
•
Pediatric CT protocols developed, labeled and consistently used
Right Report
•
Optimize radiation dose for pediatric head computed tomography (CT)
Right Action
•
Quality data and performance improvement reported to organizations’ Quality Committee and shared with
Emergency Department leadership
DLP by Age Category
• 0 – 2 Years of age
• 3 – 5 Years of age
• 6 – 11 Years of age
• 12 – 17 Years of age
Percent Pediatric Single Phase Head CTs
• Numerator: Number of pediatric inpatient and
outpatient single phase head CTs performed in the
month
• Denominator: Number of pediatric inpatient and
outpatient single phase and dual phase head CTs
performed in the month
Percent Pediatric Single Phase Chest CT
• Numerator: Number of pediatric inpatient and
outpatient single phase chest CTs performed in the
month
• Denominator: Number of pediatric inpatient and
outpatient single phase and dual phase chest CTs
performed in the month
Radiation Dose Savings
Washington reduced the
radiation dose in 10,937
children – this translates
into 21 elementary
schools full of children!
Data Collection Aligning with National
Recommendations
Thank you for attending
• Presentations:
www.childrenshospitals.org
• Presenter contact information:



Dave Wilson
Washington State Hospital Association
[email protected]
26
Safe Pediatric Imaging
St. Louis Children’s Hospital
James R Duncan, MD, PhD
Date, time
Disclosures
•
Scientific Advisor: Proteon, Metaactive, Flow Forward
•
•
Board of Directors
•
•
Former graduate student with/ three startups investigating drugs and
products for dialysis access and vascular interventions
American Board of
Radiology Foundation
Father with 3 sons
•
•
“In the blink of an eye”
I am not getting any
younger
2
Tale of Two Hospitals
•
Where I would want to be
a patient?
•
Huge differences in culture
•
Children’s Hospital
•
•
Focus on the long term future
Greater emphasis on teamwork
•
Many conversations get redirected when
someone asks “what is best for the patient?”
“Team Sophie”
3
The Opportunity
•
Most imaging occurs outside children’s hospitals
•
•
Adults (>99%); Children (>80%)
Extra care when imaging children
•
Part patient size, part adjusting scanner settings
13 yr old with
Inflammatory
bowel disease
BJH DLP=672
SLCH DLP=230
4
Burning Platform for Our Hospital Network
•
New Joint Commission
requirements (July 2016)
•
•
•
•
Pediatric protocols
Monitor dose metrics
Establish expected ranges and
investigate outliers
Prompted action at all 12 hospitals
•
•
Academic/private; pediatric/adult;
tertiary/community
Resulted in an enterprise wide
oversight committee
Cat herding
5
Difference Between Peds/Adult CT Protocols
6
Difference Between Peds/Adult CT Protocols
7
Facilitating Large Scale Changes
Optimizing radiation use
• Children’s hospitals are
clear leaders
– Current focus is children
– What about young adults?
• Need to build capacity and
disseminate knowledge
Institute for Healthcare Improvement’s model
8
BJC Health Care
9
10
Progress but ….
Opportunities remain
11
Summary
•
Goal state: Best possible outcomes
•
•
•
Accurate diagnosis
Minimal radiation exposure
Every child, Every day, Every site
•
•
“The relentless pursuit of perfection*”
Requires
•
•
Data collection and analysis
Teamwork
•
•
Physicians, techs, nurses, physics, admin, …
Willingness to share the lessons learned
*Former tagline for Lexus
From Despair.com
12
Proposed 2017 National Patient Safety Goal
#1 Implement evidence-based practices for CT imaging of pediatric patients with
minor head trauma. Note: Organizations are expected to adopt evidence-based
practices such as the Pediatric Emergency Care Applied Research Network’s
(PECARN) Childhood Head Trauma: A Neuroimaging Decision Rule, which
predicts the need for brain imaging after pediatric head injury.
#2 Implement criteria for the appropriate use of dual-phase CT examinations (with
and without contrast) of the head and chest for pediatric patients.
#3 Establish goals for compliance with #1 and #2 above.
#4 Take steps to improve when performance does not meet these goals.
13