Improving the Quality of Radiographs in Neonatal Intensive Care Unit Utilizing Educational Interventions

Abstract

Objective We aimed to develop an educational tool to improve the radiograph quality, sustain this improvement overtime, and reduce the number of repeat radiographs.

Study Design A three phase quality control study was conducted at a tertiary care NICU. A retrospective data collection (phase1) revealed suboptimal radiograph quality and led to an educational intervention and development of X-ray preparation checklist (primary intervention), followed by a prospective data collection for 4 months (phase 2). At the end of phase 2, interim analysis revealed a gradual decline in radiograph quality, which prompted a more comprehensive educational session with constructive feedback to the NICU staff (secondary intervention), followed by another data collection for 6 months (phase 3).

Results There was a significant improvement in the quality of radiographs obtained after primary educational intervention (phase 2) compared with phase 1 (p < 0.001). During interim analysis after phase 2, radiograph quality declined but still remained significantly better than phase 1. Secondary intervention resulted in significant improvement in radiograph quality to > 95% in all domains of image quality. No radiographs were repeated in phase 3, compared with 5.8% (16/277) in phase 1.

Conclusion A structured, collaborated educational intervention successfully improves the radiograph quality and decreases the need for repeat radiographs and radiation exposure in the neonates.

Keywords

radiographs - quality improvement - neonates - radiation - education

• References

• 1 Sutton PM, Arthur RJ, Taylor C, Stringer MD. Ionising radiation from diagnostic x rays in very low birthweight babies. Arch Dis Child Fetal Neonatal Ed 1998; 78 (3) F227-F229
• 2 Wilson-Costello D, Rao PS, Morrison S, Hack M. Radiation exposure from diagnostic radiographs in extremely low birth weight infants. Pediatrics 1996; 97 (3) 369-374
• 3 Donadieu J, Zeghnoun A, Roudier C , et al. Cumulative effective doses delivered by radiographs to preterm infants in a neonatal intensive care unit. Pediatrics 2006; 117 (3) 882-888
• 4 Arad I, Simanovsky N, Braunstein R. Exposure of extremely low birth weight infants to diagnostic X-Rays: a longitudinal study. Acta Paediatr 2009; 98 (2) 266-269
• 5 Vachharajani A, Vachharajani NA, Najaf T. Neonatal radiation exposure. Neo Rev 2013; 14 (4) e190-e197
• 6 Berrington de González A, Darby S. Risk of cancer from diagnostic X-rays: estimates for the UK and 14 other countries. Lancet 2004; 363 (9406) 345-351
• 7 Hall P, Adami HO, Trichopoulos D , et al. Effect of low doses of ionising radiation in infancy on cognitive function in adulthood: Swedish population based cohort study. BMJ 2004; 328 (7430) 19
• 8 Dougeni ED, Delis HB, Karatza AA , et al. Dose and image quality optimization in neonatal radiography. Br J Radiol 2007; 80 (958) 807-815
• 9 Hellwig BJ, Wilson B. Quality improvement related to radiation safety chest radiography in the NICU. Radiol Manage 2013; 35 (2) 18-23 , quiz 24–25
• 10 Loovere L, Boyle EM, Blatz S, Bowslaugh M, Kereliuk M, Paes B. Quality improvement in radiography in a neonatal intensive care unit. Can Assoc Radiol J 2008; 59 (4) 197-202
• 11 Ballinger PW, Frank ED. Merrill's Atlas of Radiographic Position and Radiologic Procedure. Vol 3. St. Louis, MO: Mosby; 2003
• 12 Meerstadt PWD, Gyll C. Manual of Neonatal emergency X-ray Interpretation. London (GB): WB Saunders; 1994: 1-6
• 13 Simanovsky N, Ofek-Shlomai N, Rozovsky K, Ergaz-Shaltiel Z, Hiller N, Bar-Oz B. Umbilical venous catheter position: evaluation by ultrasound. Eur Radiol 2011; 21 (9) 1882-1886
• 14 Katheria AC, Fleming SE, Kim JH. A randomized controlled trial of ultrasound-guided peripherally inserted central catheters compared with standard radiograph in neonates. J Perinatol 2013; 33 (10) 791-794
• 15 Dennington D, Vali P, Finer NN, Kim JH. Ultrasound confirmation of endotracheal tube position in neonates. Neonatology 2012; 102 (3) 185-189
• 16 Bussières AE, Sales AE, Ramsay T, Hilles SM, Grimshaw JM. Impact of imaging guidelines on Xray use among American provider network chiropractors: interrupted time series analysis. Spine J 2014; 14 (8) 1501-1509
• 17 Cobo ME, Vicente A, Corres J, Royuela A, Zamora J. Implementing a guideline for the request of chest and abdominal x-rays in nontrauma pathologic conditions in an ED. Am J Emerg Med 2009; 27 (1) 76-83
• 18 McWhirter E, Yogendran G, Wright F, Pharm GD, Clemons M ; Cancer Care Ontario Practice Guidelines Initiative. Baseline radiological staging in primary breast cancer: impact of educational interventions on adherence to published guidelines. J Eval Clin Pract 2007; 13 (4) 647-650
• 19 John SD, Moore QT, Herrmann T , et al. The Image Gently pediatric digital radiography safety checklist: tools for improving pediatric radiography. J Am Coll Radiol 2013; 10 (10) 781-788
• 20 Thomas SM, Burch W, Kuehnle SE, Flood RG, Scalzo AJ, Gerard JM. Simulation training for pediatric residents on central venous catheter placement: a pilot study. Pediatr Crit Care Med 2013; 14 (9) e416-e423
• 21 United Nations Scientific Committee on the Effects of Atomic Radiation. Sources and effects of ionizing radiation. Available at: http://www.unscear.org/docs/reports/2008/11-80076_Report_2008_Annex_D.pdf . Accessed September 12, 2012
• 22 Don S, Macdougall R, Strauss K , et al. Image gently campaign back to basics initiative: ten steps to help manage radiation dose in pediatric digital radiography. Am J Roentgenol 2013; 200 (5) W431-6