Chapter 23

Chapter 23: Justification and
Optimisation in Clinical Practice

Slide set of 138 slides based on the chapter authored by
M. Sandborg, M. Båth, H. Järvinen and K. Faulkner
of the IAEA publication (ISBN 978-92-0-131010-1):
Diagnostic Radiology Physics:

A Handbook for Teachers and Students
Objective:
To familiarize the student with principles and practices
associated to justification and optimization.
Slide set prepared

by K.P. Maher, PhD
following initial work by
S. Edyvean, MSc
IAEA
International Atomic Energy Agency
CHAPTER 23 TABLE OF CONTENTS
23.1 Introduction
23.2 Justification
23.3 Optimization
23.4 Clinical Audit
Bibliography
IAEA
Diagnostic Radiology Physics: a Handbook for Teachers and Students – chapter 23, 2
23.1 Introduction
23.2 Justification
23.2.1 Referral Guidelines for Imaging
23.2.2 Sensitive Populations
23.2.3 High Skin Dose Examinations
23.2.4 Population Screening
23.2.5 Informed Consent
23.3 Optimization
23.3.1 Equipment, Guidelines & Image Criteria
23.3.2 Good Practice
23.3.3 Optimisation – Two Practical Examples
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23.4 Clinical Audit

23.4.1 Objectives
23.4.2 Coverage of Radiological Practices
23.4.3 Standards of Good Practice
23.4.4 Relationship with Other Quality Assessments &
Regulatory Control
23.4.5 Methods and Practical Organization
23.4.6 Role of the Medical Physicist
Bibliography
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23.1 INTRODUCTION
All medical exposures must be subject to the principles of

justification and optimisation of Radiological Protection which
are common to all practices dealing with potential exposures of
humans to Ionising Radiation
Justification of medical exposures may be stated as follows:
All medical imaging exposures must show a

sufficient net benefit when balanced against
possible detriment that the examination might
cause
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23.1 INTRODUCTION
For patients undergoing medical diagnosis or treatment, there

are different levels of justification
The practice involving exposure to radiation must be justified in

principle
through the endorsement of relevant professional

societies
as matters of effective medical practice will be central to this

judgement
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23.1 INTRODUCTION
Also, each procedure should be subject to a further, case-by-

case, justification by both the
Referring Clinician who is responsible for the

management of the patient and the
Radiologist who selects the most appropriate
imaging examination to answer the referrer’s
question
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23.1 INTRODUCTION
In addition to the requirements of Optimisation of Radiological

Protection:
the concept of Optimisation of Clinical Practice in
diagnostic radiology must also be considered
This is the process requiring diagnostic outcome for a patient

from an imaging procedure while minimising factors that cause
patient detriment
Along with radiation related considerations these factors include

adverse patient contrast media reactions in CT and
interventional radiology
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23.1 INTRODUCTION
Optimisation is a multidisciplinary task involving the medical

physicist, radiologist, radiographer, hospital or vendor engineer and
department management
It is a cyclical process comprising:

Evaluation of clinical image quality and patient dose to identify
the need for action
Identification of the possible alternatives to maintain necessary
image quality and minimising patient absorbed doses
Selection of the best imaging option under the given
circumstances
Implementation of the selected option
Regular review of image quality and patient dose to evaluate if
either requires further action
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23.1 INTRODUCTION
One key element in managing quality in health care is Clinical

Audit
Clinical audit is a systematic review of the medical procedures

against agreed standards for good procedures
seeking to improve the quality and outcome of

patient care
It is applicable to justification and optimisation and is reviewed

later in this chapter
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23.2 JUSTIFICATION
Justification of medical exposures is the responsibility of both

the radiological medical practitioner and the referring medical
practitioner
A medical exposure is justified if it provides:
a Benefit to the patient in terms of relevant diagnostic

information and
a Potential Therapeutic Result that exceeds the

detriment caused by the examination
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23.2 JUSTIFICATION
Imaging methods with less patient effective dose should be

considered if the same diagnostic information can be obtained
This is true for all patients but especially important for younger
patients
No new imaging modality should be established unless the

exposed individuals or society have a net benefit to offset the
detriment
Justification of medical exposures should be made on three

levels - see the following table
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23.2 JUSTIFICATION
LEVELS OF JUSTIFICATION OF MEDICAL EXPOSURES
Use of radiation for diagnosis in medicine is

1
generally accepted
Use of radiation in a specific procedure for a

2
specific objective is justified
Use of radiation for an individual patient should be

3
justified prior to the examination
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23.2 JUSTIFICATION
LEVEL 2
Use of radiation in a specific procedure for a specific

objective, for example mammography to follow-up after breast
cancer, is justified
It is important to evaluate if the radiological examination will

improve the accuracy of the diagnosis and treatment of
patients
Justification may need to be re-evaluated if new information or

new imaging techniques are made available
For example plain radiography of the lumbar spine for acute back pain or
disk hernia except for osteoporotic collapse may not be justified but MRI or
CT considered instead
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23.2 JUSTIFICATION
LEVEL 3
Use of radiation for an Individual Patient should be justified

prior to the examination
Here:
the Specific Reasons of the exposure and
the Explicit Conditions of the patient
should be considered
Referral Guidelines are an important tool in this evaluation
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23.2 JUSTIFICATION
LEVEL 3
The request for a radiological examination should convey all

relevant information in order for the radiologist to decide on the
best radiological procedure
Communications between the referring clinician and the

radiologist are very important
Pregnancy and allergy to contrast media should also be

considered, as should any relevant previous examination or
information in the patient’s medical record
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23.2 JUSTIFICATION
Referral Guidelines for imaging are precise statements to help

the clinician in making correct decisions on which type of
radiological examination is most appropriate given the clinical
conditions
While such guidelines are not absolute rules, there must be

good reasons for ignoring them, as they are examples of Good
Practice
The objectives of the referral guidelines are to improve clinical

practice, to reduce the number of unnecessary examinations
and hence to reduce Unnecessary Medical Exposure
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23.2 JUSTIFICATION
The main target group of the guidelines is Referring

Clinicians
Medical Physicists can, however, also benefit from studying

the general scheme of the guidelines in order to better co-
operate with medical staff in using the guidelines
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23.2 JUSTIFICATION
In Europe, referral guidelines for imaging have evolved from the

United Kingdom Royal College of Radiologist publication
‘Making the best use of clinical radiology services’
European radiological societies in member states have

contributed to an evidenced-based booklet adopted by the
expert groups ‘Referral guidelines for imaging’
The American College of Radiologists have published

‘Appropriateness criteria’ that are evidence-based guidelines to
assist referring clinicians in making the most appropriate imaging
decision
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23.2 JUSTIFICATION
Guidelines are important since not all medical imaging

examinations give results that alter management of the patient or
add confidence to the clinician’s diagnosis and hence may add
unnecessary radiation dose
There are several causes of unnecessary examinations:

a repeated examination when relevant information was
available but not obtained
performing an irrelevant examination
too frequent use of a particular examination
inadequate clinical information so that important clinical
questions could not be answered
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23.2 JUSTIFICATION
The recommendations in the referral guidelines for imaging are

classified as indicated when the examination is likely to
contribute to clinical diagnosis and management of the patient
Other recommendations are Specialised Examinations that are

complex, expensive and require individual discussion with an
expert radiologist
Finally the recommendations can be not indicated initially,

routinely or not recommended at all
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23.2 JUSTIFICATION
The guidelines further classify the typical effective doses in five

groups from 0 to IV, where:
Group 0 are examinations without ionising radiation
(ultrasound and MRI)
Group I examinations where the effective dose is less
than 1 mSv (e.g. limb and plain chest radiography)
In Groups II-IV the effective doses are:

1-5 mSv (e.g. IVU)
5-10 mSv (e.g. CT chest) and
>10 mSv (e.g. PET/abdominal-CT)
respectively
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23.2 JUSTIFICATION
It is recognised that the Cancer Excess Mortality by age of

exposure is ~2-3 times higher for children than for the average
population
It is therefore particularly important to
optimise the imaging conditions for children
Typically, however, lower patient doses are used in Paediatric

Radiology simply because the body or body part of the child is
smaller than that of the adult
European guidelines with image criteria and criteria for

radiation dose are available for common paediatric
examinations but surveys show that the dose to the child can in
some cases be reduced further
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23.2 JUSTIFICATION
Contrast media are sometimes necessary to visualise different

soft tissues and vessels since the object contrast is inherently
too low
The ideal contrast media will attenuate the X ray beam more
than surrounding tissue but otherwise leave body organs
unaffected
This is not always possible
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23.2 JUSTIFICATION
Some patients react negatively to injected iodine contrast media

with acute (i.e. within two hours) or late (i.e. within two weeks)
side-effects, which may be severe
Special caution needs to be taken with patients with kidney

problems or with diabetes
The use of contrast media must be evaluated prior to imaging

such patients
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23.2 JUSTIFICATION
Some interventional radiological procedures may in addition to

high equivalent doses to internal organs also result in such high
local skin or eye lens doses that there is Deterministic (acute)
radiation damage
Examples of deterministic radiation damages include skin

erythema and temporary epilation or lens cataract with visual
impairment
The ICRP gives guidance on how to identify and manage

patients with potential high doses to their skin
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23.2 JUSTIFICATION
In these situations it is important that the staff document
the measures of absorbed dose that the

imaging equipment provides
after the procedure so that any subsequent radiation injury can

be managed properly
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23.2 JUSTIFICATION
Diagnostic procedures are examinations of individuals that

have some signs or symptoms of disease
Population screening, on the other hand, is a systematic testing

of Asymptomatic Individuals for a disease between its actual
onset and display of its symptoms
The Objective for Screening is to detect the disease while

treatment will have highest effect
Therefore Specific Guidelines and criteria for screening

procedures and selecting individuals for screening are
particularly important
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23.2 JUSTIFICATION
The problem of selecting the proper screening procedure lies

in the imaging procedure’s ability to separate an early
manifested disease in a healthy population
The adverse effects of, for example, Cancer Screening are:

the radiation dose and the potential cancer it may
induce later in life
the risk of False Positive Cases with possible anxiety
and unnecessary and potentially harmful subsequent
examinations and of course
potential harmful treatment
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23.2 JUSTIFICATION
Patients undergoing medical imaging procedures should prior

to the examination be informed of the potential risk associated
with the examination
This includes the risk of:
allergic reactions to intravenous injected contrast

media and
potentially high skin doses following sometimes
lengthy imaging sessions
for example percutaneous coronary intervention, PCI
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23.2 JUSTIFICATION
Healthy volunteers or patients undergoing alternative or

experimental imaging procedures must also be properly
informed of the risks
The scientist managing such research must seek and obtain

approval by the Ethics Committee in advance in accordance
with national legislation
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23.3 OPTIMIZATION
Working as a medical physicist with responsibility for

optimisation of radiographic procedures, it is necessary to use
a Strategy to perform the optimisation work in an efficient
way
Different Approaches for such strategies exist
For example, it could be argued that it is most important that

the examinations that result in the highest patient doses – on
an individual level or a population level – are optimised first
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23.3 OPTIMIZATION
An Alternative Strategy is to focus on examinations that have

questionable image quality as such examinations have the risk
of
not providing the necessary diagnostic
information
No matter what strategy is chosen, it is obvious that

examinations that have questionable image quality, are of high
importance for the patient and result in high radiation doses
should be optimised first
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23.3 OPTIMIZATION
Then it is important to carefully think about what methods to

use for the actual optimisation
As optimisation involves both radiation dose and image quality,

it is necessary to decide what relevant measures to use
Since for most radiographic procedures it is the Stochastic

Risk of radiation that is of interest, a dose measure that can be
used to estimate this risk should be used
Effective Dose
is therefore often the natural choice
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23.3 OPTIMIZATION
Although the use of effective dose for individual patients is not

appropriate, it is suitable for groups of patients and for the
purpose of comparing:
Relative Risk between different radiological

examinations or
Doses before and after a change in imaging
conditions
The age and gender of the patients need to be considered for

a proper risk evaluation
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23.3 OPTIMIZATION
For mammography, the mean glandular dose to the breast

tissues is generally used
It could be argued that for procedures for which there is a risk

of deterministic injuries, such as interventional radiological
procedures, other dose measures, such as Skin Dose, are
also relevant
However, such injuries are rare events and can in most

situations be avoided if the personnel are adequately trained
and the imaging system is not malfunctioning
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23.3 OPTIMIZATION
Regarding Image Quality, there is a large variety of methods

intended for evaluation of this somewhat diffuse measure
No matter what method is chosen, it is important to bear in

mind that the validity of the results is limited by the validity of
the method
Thus, the method used should preferably incorporate the

entire imaging chain
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23.3 OPTIMIZATION
As the current gold standard for determining image quality is

ROC-based methods, the use of such methods may be
advocated for optimisation
However, conducting ROC studies may be a cumbersome

task, and they may therefore not be best suited for the daily
optimisation work
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23.3 OPTIMIZATION
Visual Grading is a common and very practical methodology

used for the determination of image quality in optimisation as
an alternative to the ROC approach
It uses Observers’ Ratings of the visibility of structures in the

image
The ratings are then used to establish a measure of image

quality
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23.3 OPTIMIZATION
Visual Grading has the strengths that the entire imaging

chain can be included in the evaluations
The task of the observer resembles that of the radiologist in

everyday work:
deciding whether a given image can be used for

the required task of detecting abnormality or not
A successful visual grading study is based on letting the

observers judge the visibility of the structures that are
important to be well visualised in the examination
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23.3 OPTIMIZATION
Commonly reported weaknesses with visual grading are that it

is somewhat subjective and that it is prone to bias
This is definitely true
However, radiologists rely on their subjective impression in

their daily diagnostic work and it is difficult to remove this
limitation without excluding the radiologist from the image
quality assessment
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23.3 OPTIMIZATION
There are many differences between analogue screen-film

systems and digital systems for optimisation
The most important is the fact that while the film constitutes
both detector, processing and display media with almost fixed
properties, the digital system not only consists of independent
detector, processing and display, but also many relevant
properties of these components are adjustable
For a given screen-film system, optimisation is a limited task

due to the fixed sensitivity and latitude of the system
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23.3 OPTIMIZATION
Therefore, the most important task is to choose exposure

settings for obtaining a correct exposure
The optimisation process consists of choosing the optimal

Beam Quality (tube voltage and filtration) and Tube Charge
(‘mAs’) to match the input signal to the latitude and sensitivity
of the screen-film system
The sensitivity and latitude of the screen-film system can be

altered by changing the screen and film, respectively
In this way, a noise level or spatial resolution suitable for a

given examination can be obtained
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23.3 OPTIMIZATION
For Digital Systems, the displayed image contrast can be

adjusted without clinically relevant restrictions, which can be
interpreted as if the system has adjustable sensitivity and
latitude
The two most important tasks for optimisation of a screen-film

system:
correct detector dose to obtain optimal optical density
correct beam quality to adapt the attenuation differences in
the object to the latitude of the system
are therefore of little relevance for digital systems

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23.3 OPTIMIZATION
Instead, optimisation of digital equipment can be more focused

on actually finding the parameter combination (exposure
parameters, image processing parameters, etc.) that results in
the best image quality for a given effective dose
or other relevant dose measure
Finally you need to decide on the appropriate Tube Charge

(‘mAs’) that provides sufficiently low noise given the clinical
requirements
In this way, the necessary image quality is obtained at the

lowest possible exposure of the patient
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23.3 OPTIMIZATION
23.3.1 Equipment, Guidelines & Imaging Criteria
The European Union has, for some common radiographic

examinations, published guidelines that give diagnostic
requirements, criteria for radiation dose and examples of good
radiographic technique
The requirements include both image criteria and important

image details and apply to standard sized patients with the
usual symptoms for that type of examination
The Image Criteria are important anatomical structures that

should be visible in the images
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23.3 OPTIMIZATION
Typically the criteria are expressed in several degrees of

visibility
For example:
Visually Sharp Reproduction means that the details
are clearly defined
whereas
Visualisation reflects a situation where the details are
detected but not fully reproduced
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23.3 OPTIMIZATION
The list of important image details gives the minimum

dimensions in the image at which normal or abnormal
anatomical details should be recognised
The criteria have been further developed over the years to be

more specific to changes in the imaging condition for use in
Visual Grading evaluations of clinical images
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23.3 OPTIMIZATION
The criteria given in the EU document for radiation doses to

the patient are expressed in terms of Entrance Surface Dose
However the IAEA code of practice recommends the use of Air

Kerma-Area Product, PKA, as the dosimetric quantity in
fluoroscopy
The advantage of PKA over entrance surface dose is that the

radiation beam size is directly included in the measurement
and that PKA values for different projections can be added
together with reasonable validity
Adding entrance surface dose from
different projections is not meaningful
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23.3 OPTIMIZATION
Internationally the concept of Diagnostic Reference Levels

has been implemented in some countries and diagnostic
standard doses are periodically measured locally in the
hospitals and compared to the reference levels
If the reference level is exceeded in a particular X ray room,

the hospital needs to:
Review their imaging conditions
Consider and possibly implement corrective actions to
reduce the dose
if the clinical image quality
requirements can still be met
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23.3 OPTIMIZATION
The implementation of diagnostic reference levels has led to
reduction in patient absorbed doses
It must be considered as a
successful radiological protection action

and
a first step towards achieving optimal imaging

conditions
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23.3 OPTIMIZATION
As an example, European guidelines for an examination of the urinary tract:
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23.3 OPTIMIZATION
The important details in urinary tract examination are 1 mm

calcifications
The image criteria require reproduction of the area of the

whole urinary tract from the upper pole of the kidney to the
base of the bladder as well as reproduction of the kidney
outlines
The psoas outlines should be visualised and visually sharp

reproduction of the bones is required
The criterion for entrance surface dose for a standard-sized

patient is 10 mGy
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23.3 OPTIMIZATION
Listed below are some aspects associated with good radiological practice:
Pregnant patient and foetus protection
Adopting the exposure setting to patient size
Managing high local skin doses
Positioning of the patient
Limiting the radiation field
Protective shielding
Compression
Photon energy
Low-attenuating materials
Scatter rejection methods
Automatic exposure control, AEC setting
Appropriate film optical density or background quantum noise level
Viewing conditions
Each will be considered in turn
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23.3 OPTIMIZATION
Some are related to the management of procedures for

examining pregnant patients and of handling patients receiving
high absorbed doses
Others are related to performing the examination such as:
Positioning of the patient and radiation field

Selecting the most appropriate examination technique
Circumstances for Reading the images
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23.3 OPTIMIZATION
Pregnant Patient & Foetus Protection

Prior to an examination in the lower abdomen region women
should be asked if they are pregnant
If the woman is pregnant or pregnancy cannot be ruled out and

if the primary beam is located close to the foetus, the
examination should be postponed until the baby is born
provided this is acceptable from a clinical point of view
If postponing the examination is not possible, an examination

without ionising radiation should be considered if sufficient
diagnostic information could be expected
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23.3 OPTIMIZATION
If this also is not possible, the examination should be performed

but special measures should be taken to minimise the dose to
the foetus
The decision should be noted in the patient’s medical records
This applies especially to an examination with relatively high

dose (e.g. CT of the lower abdomen, urography, colon and
interventional procedures in that region)
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23.3 OPTIMIZATION
Methods to minimise the dose to the foetus should be listed in

the procedure documentation and may include limiting the
number of projections, use of low-dose irradiation protocols and
careful collimation of the primary radiation beam
If the foetus is exposed by either a planned or accidental

medical exposure for example trauma CT of unconscious
pregnant woman the Medical Physicist should be contacted to
estimate the foetus dose in order for the clinician to inform the
woman in due course of the risks involved
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23.3 OPTIMIZATION
Adopting the Exposure Setting to Patient Size

As the relationship between the exposure setting used and the
resulting image quality and patient dose is dependent on the
size of the patient, it is important to adjust the exposure setting
to the size of the patient
This is of particular importance for paediatric CT
Prior to the introduction of tube current modulation in CT, the

radiation dose levels used in paediatric CT often were too high
If adult settings were employed, small children would obtain

radiation doses several times higher than adults
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23.3 OPTIMIZATION
Tube current modulation has partially solved this problem, as

the tube current used is automatically adjusted according to
patient size and density
However, it is still necessary to find the optimal dose level as

different tube current modulation techniques behave in
different ways
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23.3 OPTIMIZATION
Also, the relationship between image quality and noise level is

dependent on patient size
This is mainly due to the fact that the internal structures of

children are smaller
But also that children typically have less intra-abdominal fat

which requires the image noise to be lower (and dose higher)
to delineate organs
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23.3 OPTIMIZATION
Managing High Local Skin Doses
The patient should be placed close to the image detector, with

the tube as far from patient as possible in order to:
Minimise local entrance skin dose and

Reduce the effect of geometrical unsharpness
In interventional radiological procedures, this is particularly

important as long fluoroscopy times and multiple exposures can
be anticipated
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23.3 OPTIMIZATION

Local skin dose can be high if the same projection is
maintained throughout the whole or a large fraction of the
procedure
Changing the projection slightly may reduce the local skin

dose below that for deterministic skin injuries, but will not
necessarily reduce the dose to internal organs or the stochastic
radiation risk
To further reduce local skin dose, additional copper filtration

can dynamically be inserted into the X ray beam provided the
generator power is sufficient
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23.3 OPTIMIZATION
Additional copper filtration increases the mean energy of the

primary X ray beam and increases the relative transmission
through the part being imaged and hence for fixed image
detector dose decreases the dose to the skin of the patient
The documentation of high skin dose is facilitated by use of

the cumulative dose at the so-called Interventional Reference
Point
For fluoroscopy units, this point is located 15 cm from the isocentre towards
the XRT
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23.3 OPTIMIZATION
Positioning of the Patient

The patient should be accurately positioned by the
radiographer to allow the area of interest to be properly
imaged
To minimise patient movement immobilization equipment

should be readily available when needed
In paediatric radiology, the correct positioning of the child

may be more difficult than for an adult patient
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23.3 OPTIMIZATION
An accompanying person, for example a parent, should

preferably assist in immobilizing the child to ensure that the
radiographic projection is properly centred and collimated
The parent should be given appropriate protective clothing

(i.e. protective apron, thyroid shield) and their hands should
not be directly exposed to the primary beam
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23.3 OPTIMIZATION
In CT it is particularly important to place the patient in the

centre of the gantry to match the shape of the CT beam-
shaping bowtie-filters
Otherwise the patient will be overexposed and image

artefacts may appear
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23.3 OPTIMIZATION
Limiting the Radiation Field

Limiting the radiation field to the area of interest will both:
Reduce the radiation risk and
Improve image quality
as, for a smaller irradiated volume, less scattered radiation will reach the image detector
For example, in fluoroscopy, reducing the radius of the

primary beam from 12 cm to 9 cm will
almost half
the air kerma area product, PKA
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23.3 OPTIMIZATION
Limiting the Radiation Field
The primary radiation field should not extend beyond the active
area of the image detector
This may not always be properly considered in:

Dental Radiology (with rectangular image detectors and
circular primary beam collimation) and
Computed Tomography where the dose profile, in some
cases, is much wider than the sensitivity profile
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23.3 OPTIMIZATION
Protective Shielding
Protective shielding should not typically be used on patients

with a few exceptions e.g.
Thyroid Shield in intra-oral radiography and
Male Gonad Shields whenever the testicles are in or a
few cms outside the primary radiation beam
In such situations their use is recommended when the

protective shield does not obscure any important radiological
structure or result in image artefacts
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23.3 OPTIMIZATION
Compression
Examination of a small body or body part typically results in
lower absorbed doses due to the shorter path length through
tissue and decreased attenuation of the primary beam
Methods to reduce this path length by Compressing the body

or body part can therefore result in significant dose reduction
For example, if the patient’s abdomen can be made 3 cm

thinner in the central beam direction, the tube charge (‘mAs’)
can be reduced by ~50% whilst maintaining dose at the image
detector
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23.3 OPTIMIZATION
Compression
Positioning a patient scheduled for a lumbar spine frontal view
in PA position will allow the patient to compress themselves
By doing so the irradiated volume may be reduced and the degrading effect of
scattered radiation on image quality will also be reduced
Furthermore, some tissue may be displaced out of the primary

X ray beam and hence receive a reduced dose
Compression is generally used in mammography where, in

addition to reducing the mean glandular dose, it has many
other benefits
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23.3 OPTIMIZATION
Photon Energy
The energy of the X ray beam should be adapted to the
thickness of the part of the patient being imaged and the
diagnostic tasks
Traditionally:
Lower tube voltages (25-60 kV) are used for thin body
sections such as extremities and female breast
Intermediate tube voltages (60-120 kV) for imaging of
the abdomen and when iodine contrast media are used, but
High tube voltages (>120 kV) for chest radiography and
computed tomography
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23.3 OPTIMIZATION
Photon Energy
However, the selection of tube voltage is in many cases
based on empirical data from screen-film radiography where:
Image Contrast is not adjustable after exposure and
Total Exposure (i.e. tube charge) is determined by
properly exposing the film to achieve an appropriate optical
density
These restrictions do not apply in DR

and
Tube voltage and tube charge should be selected based on
other principles, for example detection of pathology
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23.3 OPTIMIZATION
Photon Energy
When a fixed energy imparted per unit area to the image
detector is required for properly exposing a screen-film system,
the combination of higher tube voltages and lower tube
charges typically results in lower effective dose to the patient
In DR, the opposite combination may be optimal
There are some indications that lower tube voltages than

typically used in skeletal examinations and in examinations
with iodine contrast media are more appropriate
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23.3 OPTIMIZATION
Low-Attenuating Materials
Any absorbing material between the patient and the image
detector will reduce the radiation fluence rate at the image
detector and lead to a loss of image information
If an AEC system is used, the exposure time will automatically

increase with increasing amounts of absorbing material
between patient and image detector to compensate, leading to
an increase in patient dose
Consequently efforts should be made to reduce this

absorption
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23.3 OPTIMIZATION
Such materials are the image detector protective coating, AEC-

chambers, couch, cushion and anti-scatter grid
Today, most of these are made from low-atomic number, low

density materials such as plastic or carbon fibre with the
exception, of course, of the lead strips in the anti-scatter grid
Also without an AEC, the exposure setting may need to be

altered but this will need to be made manually by the
radiographer
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23.3 OPTIMIZATION
It should be noted that if the XRT is situated below the patient
as is common in fluoroscopy and

interventional radiology
the couch and cushion add extra beam filtration but do not
necessarily increase patient exposure
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23.3 OPTIMIZATION
Scatter Rejection Methods
The majority of the photons exiting the patient are scattered in

the patient and have changed direction before reaching the
image detector plane
These photons will not convey information about the patient

and will, if they are not removed before being absorbed in the
image detector, reduce the contrast and add noise to the
image
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23.3 OPTIMIZATION
Three main methods are used to minimize the contribution of

scattered photons to image formation
The most dose-efficient method is a Scanning Fan-Beam

Assembly
Here only a small fraction of the patient is irradiated at a time,

with one or several moving narrow collimators before and
after the patient allowing all primary photons but only a small
fraction of the scattered photons to reach the image detector
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23.3 OPTIMIZATION
The second method is to increase the distance between the

patient and image detector to 20-40 cm to allow the scattered
photons to some extent miss the image detector
This method is often used when small volumes are irradiated

such as limb radiography and small children
In these situations this Air-Gap Technique is also more dose-

efficient than the third and most common method, the Anti-
Scatter Grid technique
IAEA
23.3 OPTIMIZATION

The grid consists of thin lead strips separated by a low-density
material
to allow a large fraction of the primary
photons to pass through but selectively absorb the scatter
With increasing Grid Ratio the solid angle that allows

scattered photons to pass decreases and the efficiency of the
grid increases
provided the interspace material between the
lead strips is made of low atomic number and density such as
fibre material and not aluminium
IAEA
23.3 OPTIMIZATION
The optimal grid ratio and lead strip width increase with
increasing scattering volume
The optimal grid ratio also increases with increasing lead strip
frequency (lead strips/cm), although proper alignment of the
grid becomes more critical
For this reason in bed-side chest radiography, grids with low

strip frequency, grid ratio and large focusing distance are used
IAEA
23.3 OPTIMIZATION
Automatic Exposure Control, AEC Setting
The setting of the AEC is important for both patient dose and
image quality and should be evaluated for each type of
examination
The AEC system usually consists of Ionisation Chambers

located behind the grid but before the image detector
During the exposure the signal is read from the chamber and
when the required air kerma is reached a signal is sent to the
X ray generator to terminate the exposure
IAEA
23.3 OPTIMIZATION
The AEC- system was initially designed for screen-film

radiography to assist the radiographer in obtaining the correct
exposure of the film
i.e. to match the patient structures of interest to the linear part

of the film characteristic curve
Digital image detectors have a wider useful dynamic range

and can to some extent manage over- or under-exposure
IAEA
23.3 OPTIMIZATION

Digital radiographs with different quantum noise levels,
showing anatomical structures of the temporal bones in an
anthropomorphic head phantom:
The dose and quantum noise level in the middle image are used clinically and the
consequences of increasing and reducing the dose by a factor of 5 are shown to the
right and to the left
IAEA
23.3 OPTIMIZATION
The figure shows that a variation of exposure of a factor of

twenty-five still results in a digital image with appropriate grey-
scale image contrast
However, quantum noise is very visible in the image to the left

with five times lower exposure that the one in the middle with
the clinically used exposure level
IAEA
23.3 OPTIMIZATION
Similar exposure correction systems exist in fluoroscopy units

and are denoted Automatic Brightness Control
The area used to monitor the signal level from the image
intensifier is outlined in the live-view monitor
It can to some extent be changed in size and location to adapt

to different projection requirements and FOV
IAEA
23.3 OPTIMIZATION
Appropriate Film Optical Density or

Background Quantum Noise Level
In screen-film radiography, the Optical Density of the

developed film influences image quality since the radiographic
contrast depends on the optical density
i.e. the film characteristic curve
Regular control of the film processing is important for

maintaining a consistent image quality and dose
IAEA
23.3 OPTIMIZATION

However, consistent film processing is not a sufficient

requirement for good radiographic practice as the processing
temperature may be set too low resulting in too low optical
density and contrast
This may result in increasing the required Tube Charge to

maintain sufficient image quality
IAEA
23.3 OPTIMIZATION

The sensitivity of a screen-film system depends on the
sensitivity of both the fluorescent screen and the film and will
influence the amount of quantum noise for a given optical
density
The sensitivity of the screen can be altered by either increasing

the thickness of the fluorescent screen material (absorb a
larger fraction of the photons) or by increasing the light yield
(emitting more light photons per X ray photon) or both
The latter, however, increases quantum noise

IAEA
23.3 OPTIMIZATION
Viewing Conditions
Appropriate viewing conditions will aid in reading the diagnostic
images
The Maximum Luminance of monitors ranges between 100-400 Cd/m2
With light boxes the luminance ranges from 1500-6000 Cd/m2

the higher values for mammography
The ambient light in the reading room should be kept low and
reflections of other light sources in the monitor minimised
IAEA
23.3 OPTIMIZATION
Viewing Conditions
The reader must be able to magnify the image two to four
times to resolve sub-millimetre details, as the resolution of the
image display typically is less than that of the image itself
Viewing stations of digital images should also be properly

calibrated to match the sensitivity of the human eye
Today, common practice is to calibrate diagnostic monitors

according to the Gray-Scale Standard Display Function
(GSDF) described in DICOM part 14
IAEA
23.3 OPTIMIZATION
Viewing Conditions
The GSDF aims at allowing the rendition of an image with
similar appearance on all display systems that are both GSDF-
calibrated and have the same luminance ratio
Furthermore, based on the assumption of variable adaptation,

a calibration using the GSDF results in a perceptually
linearised system
This means that a luminance change corresponding to a given

number of pixel values has the same probability of being
detected over the entire image
IAEA
23.3 OPTIMIZATION
23.3.3 Two Practical Examples
Example 1: Optimal tube charge in lumbar spine radiography
The European image criteria can be used for simple

optimisation studies together with anthropomorphic phantoms
or with patients
In the example below an anthropomorphic pelvis phantom and

seven image criteria in the lumbar spine AP projection were
used to assess clinical image quality and to identify the
required tube charge
Eight images of the pelvis phantom were obtained with

different tube charge but the same tube voltage, filtration, field
of view and post-processing etc
IAEA
23.3 OPTIMIZATION
IAEA
23.3 OPTIMIZATION
The images were assessed by a group of four radiologists and

the seven criteria were scored as either fulfilled or not fulfilled
The average fraction of fulfilled criteria was then plotted as

function of the tube charge that in this case is directly
proportional to the effective dose
IAEA
23.3 OPTIMIZATION

The figure shows the average fraction of fulfilled image criteria assessed by
radiologists for images of an anthropomorphic pelvis phantom as function of
the tube charge
The error bars represent

±1 standard deviation of the mean
IAEA
23.3 OPTIMIZATION
The figure shows that the average fraction of fulfilled criteria is

independent of the tube charge down to ~100 mAs, but that
this fraction then rapidly decreases to 0.5 with decreasing tube
charge
It was primarily the 5th image criterion and secondly the 1st
and 2nd image criteria that were rated not fulfilled when the
dose was reduced and quantum noise increased
IAEA
23.3 OPTIMIZATION
These three criteria are evaluated on a higher level of image

quality visually sharp reproduction than the others
Limitations of the phantom did not allow the 6th example

criterion to be properly evaluated by the radiologists
In this simple example, a tube charge of ~100 mAs minimises

the absorbed dose but maintains clinical image quality in terms
of fulfilment of the criteria
IAEA
23.3 OPTIMIZATION
Example 2: Optimal tube voltage for conventional urography
In the second example, it was identified that with the increasing

use of CT for urography examinations, the indications for
conventional urography, when still performed, had changed and
were more focused on high-contrast details
It therefore could not be assumed that the existing tube voltage

setting (73 kV) remained optimal for the Gd2O2S-based flat
panel image detector used, although the image quality was
acceptable
IAEA
23.3 OPTIMIZATION
The purpose of the work was therefore to optimise the tube

voltage for urography examinations for the new conditions of
the examination so that the necessary image quality possibly
could be obtained at a lower effective dose
As a first step, a phantom study was performed to investigate

a wide range of tube voltages
Images of an anthropomorphic pelvis phantom, containing

simulated contrast-filled kidneys and ureters, were collected
with the system at tube voltages from 50 kV to 90 kV at
constant effective dose
IAEA
23.3 OPTIMIZATION

Two X ray images of a pelvis phantom with an added contrast-filled
kidney collected at 50 kV (left) and 90 kV (right) that were post-
processed to achieve similar image contrast
IAEA
23.3 OPTIMIZATION
As the image display stage is separated from the image

collection stage for a DR system (contrary to a screen-film
system), the dependence of the displayed image contrast on
tube voltage can be much smaller
Hence the selection of optimal tube voltage in DR can be

different from screen-film radiography
IAEA
23.3 OPTIMIZATION
The images were analysed by radiologists in a visual grading

study, where the reproduction of the simulated renal pelvises,
calyces and ureters was rated
The tube voltage resulting in the best image quality was 55 kV,
which therefore was selected as the clinical setting
IAEA
23.3 OPTIMIZATION
After using the new setting for some time, images from a
number of patients collected with the new setting were selected
for comparison with images previously collected with the old
setting of 73 kV
The 55 kV images underwent simulated dose reduction to

represent images collected at 80, 64, 50, 40 and 32% of the
original dose level
All images were included in a visual grading study where

radiologists once again rated the visibility of the renal pelvises,
calyces and ureters
IAEA
23.3 OPTIMIZATION
Analysis of the given ratings:
The image quality measure

AUCVGC for each simulated
dose level at 55 kV in the
patient study with 73 kV
and 100% dose as
reference
IAEA
23.3 OPTIMIZATION

The analysis shows that for images collected at 55 kV, an
effective dose of ~85 % resulted in the same image quality as
for images collected at 73 kV at 100 % dose
It was therefore concluded that:

Low tube voltage should be used for conventional
urography focused on high-contrast details and
Using a tube voltage of 55 kV instead of 73 kV, the
effective dose could be reduced by ~10-20 % without
negatively affecting the image quality
IAEA
23.3 OPTIMIZATION
Interestingly, the European Guidelines suggest a tube voltage

between 75 and 90 kV for urography
This shows both that the:

Recommended technique settings for screen/film
systems are not automatically valid for digital
radiography and
Exposure parameters need revision after the
diagnostic requirements have changed
IAEA
23.3 OPTIMIZATION
The AUCVGC data can be interpreted as the proportion of

comparisons for which the image quality for the evaluated
system (here the 55 kV images at different dose levels) is rated
higher than the reference (the only alternatives for each
comparison are higher or lower image quality)
An AUCVGC of 0.5 thus corresponds to equal image quality

between the evaluated system and the reference
The figure indicates that with 55 kV, only 85% of the dose is
needed to obtain the same image quality as with 73 kV
IAEA
23.4 CLINICAL AUDIT
23.4.1 Objectives
In the European Commission Medical Exposures Directive,

clinical audit is defined as:
a systematic examination or review of medical radiological

procedures
which seeks to improve the quality and outcome of patient care
through structural review
whereby radiological practices, procedures and results are
examined against agreed standards for good medical
radiological procedures
with modification of practices where indicated and
the application of new standards if necessary
IAEA
23.4 CLINICAL AUDIT
23.4.1 Objectives
In general, the objectives of clinical audit can be distinguished

as follows:
1. Improvement in the quality of patient care
2. Promotion of the effective use of resources
3. Enhancement of the provision and organisation of
clinical services
4. Further professional education and training
With these objectives, clinical audit is an integral part of the

overall quality improvement process and should be considered
as an integral part of quality management and Clinical
Governance
IAEA
23.4 CLINICAL AUDIT
23.4.1 Objectives
Clinical audit is a truly multi-disciplinary, multi-professional

activity
It must be carried out by auditors with extensive knowledge

and experience of the radiological practices to be audited,
i.e. they must generally be professionals involved in clinical
work within these practices
Further, the general understanding of the concept Audit

implies that the review or assessment is carried out by
auditors independent of the organizational unit or practice to
be audited
IAEA
23.4 CLINICAL AUDIT
23.4.1 Objectives
Clinical audit aims at continuous improvement of the medical

practices
Therefore, it should be carried out regularly and it should be
ensured that the audit cycle is completed
The general audit cycle consists of:

• Selecting a standard of good practice,
• Assessing and comparing local practice with accepted
standards
• Implementing change when necessary, and
• Re-auditing after a certain time
Regular re-audits will improve the quality or give
reassurance that a good quality is maintained
IAEA
23.4 CLINICAL AUDIT
23.4.1 Objectives
Clinical audit should comprise both internal and external

assessments and these should supplement each other
Internal audits are undertaken within a given health care

setting by staff from the same institution, while the audit
findings can be externally reviewed
In small health care units, internal audits would rather be self-

assessments
IAEA
23.4 CLINICAL AUDIT
23.4.1 Objectives
External audits involve the use of auditors who are independent

of the radiology department/institution
External audits bring added perspectives to the audit process,

because internal auditors might not be able to see all
weaknesses in their own institution
External auditors should also possess better benchmarking

skills in relation to the assessment
IAEA
23.4 CLINICAL AUDIT
23.4.1 Objectives
Clinical audit should yield multiple benefits to the health care

system, such as:
Provision of a tool for quality improvement
Recognition of quality,
Good practices and outdated practices
Motivation of staff to increase quality improvement of
practice and local standards
Adherence to national standards
Avoidance of litigation
Improvement of communication within the institution
Revealing weak points
Promoting development of quality systems
IAEA
23.4 CLINICAL AUDIT
23.4.1 Objectives
Clinical audit should thus be able to identify the strengths of a

radiology department, as well as areas requiring improvement,
while the main beneficiary will eventually be the patient
Comprehensive guidance for clinical audits has been published

by the European Commission and the IAEA
The former provides a general framework for establishing

sustainable national systems of audit, while the latter
supplements this framework for diagnostic radiology by
introducing very practical advice for implementing external
clinical audits
IAEA
23.4 CLINICAL AUDIT
Clinical audit should cover the whole clinical pathway, and

address the three main elements of the radiological practices:
Structure: the attributes of the setting in which care

occurs, including material resources (e.g. facilities,
equipment), human resources (e.g. number, grade and
qualification of staff) and organisational structure
Process: the delivery of patient care
Outcome: the impact of the department on the health
status of patients
IAEA
23.4 CLINICAL AUDIT
A single clinical audit can:

assess either the whole clinical pathway of the
radiological process, from referral to follow up
(Comprehensive Audit), or
can be limited to specific critical parts of it (Partial
Audit)
It can assess the parts of the practices which are generic either
to all radiological procedures or
to a given speciality (e.g. for CT), or
can go deeper to a selected individual examination

IAEA
23.4 CLINICAL AUDIT
Clinical audits should address both the
critical issues of the radiation protection for the patient

and
key components of the overall quality system
These include:
Justification and
Optimisation
as essential parts of the process
IAEA
23.4 CLINICAL AUDIT
Auditing the examination specific practices can usually means

only a few selected examination types per audit
Full details of the procedures should be assessed at least for

the parts where a reasonable consensus on a good practice
can be achieved, such as:
Indications
Image criteria, reproduction of anatomical structures
Patient position and imaging parameters
Protective shielding
IAEA
23.4 CLINICAL AUDIT
Before starting the clinical audit the critical areas should be

identified and the objectives agreed
For internal audits, the objectives are set by the management

of the health care unit to be audited
For external audits, the detailed objectives should be agreed

between the auditing organization and the unit to be audited,
and should be based on:
any legal requirements on audit programmes
any recommendations by national coordinating
organizations or by health professional and/or scientific
societies when available
IAEA
23.4 CLINICAL AUDIT
In practice, the process may be subdivided into four sections:
Quality Management Procedures and Infrastructure

Patient Related Procedures
Technical Procedures
Teaching, Training and Research
IAEA
23.4 CLINICAL AUDIT
The audit of Quality Management Procedures and

Infrastructure includes:
the mission and vision of the radiology unit
its business plan
long-term objectives and
the departmental workload/patient demographics
the department’s organisational structure
staff management processes such as programmes for
continuing professional development, working practice
instructions and protocols/procedures
departmental premises and equipment
IAEA
23.4 CLINICAL AUDIT
The audit of Patient Related Procedures includes:

the processes to ensure the appropriateness of
examination (referral guidelines used, risk benefit
considerations, contraindications etc)
processes for ensuring relevant clinical conditions are
taken into account prior to undertaking an examination
(asking about allergies, anti-coagulant therapy,
pregnancy etc)
patient identification procedures and fail safes
the policies to respect patient confidentiality, and
the protocols and procedures for imaging techniques,
clinical care, image quality reporting, accidents/incidents,
image and record retention etc
IAEA
23.4 CLINICAL AUDIT
The audit of Technical Procedures includes the:

Quality assurance infrastructure and
Equipment quality assurance procedures
Particular attention is paid to personnel, instrumentation,

management support and documentation
If the centre undertakes Research and /or Teaching, the

programmes for these activities should also be assessed
IAEA
23.4 CLINICAL AUDIT
Good Practice is the practice which can be recommended

based on the most recent considerations of evidence based
data, long term experience and knowledge gained on the
necessary structure, process and outcome
These can be based on:

Legal requirements
Ethical principles
Results of research
Consensus statements
Recommendations by learned societies
Local agreement (if there is no more universal reference)
IAEA
23.4 CLINICAL AUDIT
The definition of clinical audit presumes that suitable written

criteria for good practice are available for the assessments
The guidelines published by the IAEA include basic criteria,

and also reference other publications which can be used as a
basis for the establishment of extended criteria
International medical/scientific/professional societies could

play an important role in developing such standards
IAEA
23.4 CLINICAL AUDIT
23.4.4 Relationship with Other Quality Assessments & Regulatory Control
For external clinical audit, it is important to recognize that this

is a different concept to other activities of external quality
assessment such as quality audits for certification of a quality
system, audits for accreditation or regulatory inspections
Therefore, when defining the aims and objectives of external

clinical audits, it is important to ensure that these will
supplement rather than duplicate those of other activities
The relationship of clinical audit with other quality

assessments and regulatory control is discussed in detail in
the EC Guidelines
IAEA
23.4 CLINICAL AUDIT
Partial Audits can be carried out externally by the collection

of recordable or measurable data via mail or internet, with
central assessment of the data
For Comprehensive Audits, a site visit is needed and should

comprise:
A series of interviews
Observations
Document and data reviews
Measurements
Collection of data samples
Analysis
IAEA
23.4 CLINICAL AUDIT
Due to the multidisciplinary nature of the audit, a team of

auditors is usually needed, comprising different professionals
- radiologist, medical physicist, radiographer etc. - depending
on the scope of the audit
Besides the basic clinical competence, the auditors should

receive specific training on:
General audit procedure and techniques
Agreed audit programme
Criteria of good practices to be applied
IAEA
23.4 CLINICAL AUDIT
Once the clinical audit has been completed and the auditor’s
report with recommendations is available to all staff, the unit
should respond to the recommendations with an agreed
timeline for improvement
This is important not only to achieve maximum benefit from

the audit but also to retain the respect and motivation of the
staff for subsequent re-audits
IAEA
23.4 CLINICAL AUDIT
In collaboration with the other professionals, the Medical

Physicist has an important role in the
Planning
Preparation
Conduct
of clinical audits of radiological practices
Medical physics expertise is inevitably required for:

Judging the adequacy and quality of equipment
Assessing patient dose and physical image quality
Establishing and running the QA/QC programmes
for equipment
IAEA
23.4 CLINICAL AUDIT
Medical physicists often play a key role in the arrangements

and provisions for radiation safety of patients and staff, which
are among the major areas for clinical audits of radiological
practices
When the audit involves specific measurements or tests,
usually the physicist member takes care of these tests
Further, physicists are usually well practiced in making use of different mathematical or
statistical tools which can be of great value in organizing and analysing the audit data
For all these reasons, the audit team

should include a Medical Physicist
IAEA
Bibliography
AMERICAN COLLEGE OF RADIOLOGY, Appropriateness Criteria (2008)

EUROPEAN COMMISSION, European guidelines on quality criteria for
diagnostic radiographic images. EUR 16260 EN 1996 EC, Luxembourg
(1996)
computed tomography. EUR 16262 EN 1996 EC Luxembourg (1996)
diagnostic radiographic images in paediatrics EUR 16261 EN EC,
Luxembourg (1996)
EUROPEAN COMMISSION, Council Directive 97/43/Euratom of 30th June
1997 on health protection of individuals against the dangers of ionizing
radiation in relation to medical exposure, and repealing Directive 84/466
Euratom, Off. J. Eur. Comm. Rep. L., 180, 22-27, (1997)
IAEA
Bibliography
EUROPEAN COMMISSION, Referral guidelines for imaging. Radiation

protection 118 European Commission DG for the Environment, ISBN 92-
828-9454-1 EC, Luxembourg, (2001)
EUROPEAN COMMISSION, European Commission Guideline on Clinical
Audit for Medical Radiological Practices (Diagnostic Radiology, Nuclear
Medicine and Radiotherapy) (2009)
INTERNATIONAL ATOMIC ENERGY AGENCY , Radiological protection for
medical exposure to ionizing radiation, IAEA Safety Standards Series, No.
RS-G-1.5, IAEA Rep. No. 115 IAEA, Vienna (2002)
INTERNATIONAL ATOMIC ENERGY AGENCY, Dosimetry in Diagnostic
Radiology: An international code of practice. Technical report series 457.
ISBN 92–0–115406–2. IAEA, Vienna (2007)
INTERNATIONAL ATOMIC ENERGY AGENCY, Guidelines for Clinical
audits of Diagnostic Radiology Practices: A Tool For Quality Improvement
(QUAADRIL) IAEA, Vienna (2009)
IAEA
Bibliography
INTERNATIONAL COMMISSION ON RADIOLOGICAL PROTECTION,

Managing patient dose in digital radiography, International Commission on
Radiological Protection Rep. ICRP Publication 93, Ann. ICRP 34(1) (2004)
INTERNATIONAL COMMISSION ON RADIOLOGICAL PROTECTION,
Assessing Dose of the Representative Person for the Purpose of Radiation
Protection of the Public and the Optimisation of Radiological Protection:
Broadening the Process, ICRP Publication 101, Ann. ICRP 36(3) (2006)
INTERNATIONAL COMMISSION ON RADIOLOGICAL PROTECTION, The
2007 Recommendations of the International Commission on Radiological
Protection, ICRP Publication 103, Ann. ICRP 37(2-4) (2008)
ROYAL COLLEGE OF RADIOLOGISTS, Referral guidelines: Making the
best use of clinical radiology services, 6th edition Rep. MBUR6 (2007)
IAEA

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Chapter 23: Justification and

Optimisation in Clinical Practice

Diagnostic Radiology Physics:

Slide set prepared

23.4 Clinical Audit

All medical exposures must be subject to the principles of

Justification of medical exposures may be stated as follows:

All medical imaging exposures must show a

For patients undergoing medical diagnosis or treatment, there

The practice involving exposure to radiation must be justified in

through the endorsement of relevant professional

as matters of effective medical practice will be central to this

Also, each procedure should be subject to a further, case-by-

Referring Clinician who is responsible for the

In addition to the requirements of Optimisation of Radiological

This is the process requiring diagnostic outcome for a patient

Along with radiation related considerations these factors include

Optimisation is a multidisciplinary task involving the medical

It is a cyclical process comprising:

One key element in managing quality in health care is Clinical

Clinical audit is a systematic review of the medical procedures

seeking to improve the quality and outcome of

It is applicable to justification and optimisation and is reviewed

Justification of medical exposures is the responsibility of both

A medical exposure is justified if it provides:

a Benefit to the patient in terms of relevant diagnostic

a Potential Therapeutic Result that exceeds the

Imaging methods with less patient effective dose should be

No new imaging modality should be established unless the

Justification of medical exposures should be made on three

LEVELS OF JUSTIFICATION OF MEDICAL EXPOSURES

Use of radiation for diagnosis in medicine is

Use of radiation in a specific procedure for a

Use of radiation for an individual patient should be

Use of radiation in a specific procedure for a specific

It is important to evaluate if the radiological examination will

Justification may need to be re-evaluated if new information or

Use of radiation for an Individual Patient should be justified

Referral Guidelines are an important tool in this evaluation

The request for a radiological examination should convey all

Communications between the referring clinician and the

Pregnancy and allergy to contrast media should also be

Referral Guidelines for imaging are precise statements to help

While such guidelines are not absolute rules, there must be

The objectives of the referral guidelines are to improve clinical

The main target group of the guidelines is Referring

Medical Physicists can, however, also benefit from studying

In Europe, referral guidelines for imaging have evolved from the

European radiological societies in member states have

The American College of Radiologists have published

Guidelines are important since not all medical imaging

There are several causes of unnecessary examinations:

The recommendations in the referral guidelines for imaging are

Other recommendations are Specialised Examinations that are

Finally the recommendations can be not indicated initially,

The guidelines further classify the typical effective doses in five

In Groups II-IV the effective doses are:

It is recognised that the Cancer Excess Mortality by age of

Typically, however, lower patient doses are used in Paediatric