Optimizing radiation use during fluoroscopic procedures: a quality and safety improvement project

Purpose: The ionizing radiation used during fluoroscopically guided medical interventions carries risk. The teams performing these procedures seek to minimize those risks while preserving each procedure's benefits. This report describes a data-driven optimization strategy.

Methods: Manual and automated data capture systems were used to collect a series of different metrics, including fluoroscopy time, kerma area product, and reference point air kerma, from both adult and pediatric interventional radiologic procedures. Tools from statistical process control were used to identify opportunities for improvement and assess which changes led to improvement.

Results: Initial efforts focused on creating a system capable of reliably capturing fluoroscopy time from all interventional radiologic procedures. Ongoing data analysis and feedback to frontline teams led to the development of a manual workflow that reliably captured fluoroscopy time. Data capture was later supplemented by automatic capture of electronic records. This process exploited the standardized format (DICOM Structured Reporting) that newer fluoroscopy units use to record the radiation metrics. Data analysis found marked differences between the imaging protocols used for adults and children. Revision of the adult protocols led to a stable twofold reduction in average exposure per adult procedure. Analysis of balancing measures found no impact on workflow.

Conclusions: A systematic approach to improving radiation use during procedures led to a substantial and sustained reduction in risk with no reduction in benefits. Data were readily captured by both manual and automated processes. Concepts from cognitive psychology and information theory provided a theoretical basis for both data analysis and improvement opportunities.