Development of an Irish national policy for the management of pregnant or potentially pregnant patients that are referred for a procedure involving the use of ionising radiation.

OBJECTIVES: The management of pregnant or potentially pregnant patients who are referred for medical imaging procedures involving ionising radiation has proven to be a challenge for healthcare providers in Ireland. This has been confirmed by a number of regulatory agencies including the Environmental Protection Agency who have reported poor compliance with legislation, inadequate documentation and sub-optimal patient care. METHODS: An expert group was established to examine the issues that were at the root of these problems and produce recommendations for improvement. The issues highlighted by the group included a lack of clarity and consensus around a number of workflow issues such as exam categorisation, criteria to reasonably rule out pregnancy, dealing with paediatric patients and a protocol to allow urgent high fetal dose examinations to proceed when pregnancy cannot be excluded. The absence of a standardised national pregnancy declaration form was also identified as a contributory factor to poor regulatory compliance. RESULTS: The group produced a pregnancy policy template that healthcare providers could adopt which clarified the issues that were identified and included a standardised adult and paediatric pregnancy declaration form. The implementation of the policy template was subsequently assessed via a survey of a number of radiology departments and a representative referrer group. CONCLUSIONS: The results of these surveys revealed a substantial uptake of the template along with overall satisfaction with the contents. They also demonstrated a reduction in the use of the clinical waiver system which had been highlighted as a cause of sub-optimal patient care. KEY POINTS: • The management of pregnant or potentially pregnant patients referred for medical imaging procedures involving ionising radiation is challenging. • A new national pregnancy policy template was developed by an expert group and has been widely adopted by healthcare institutions in Ireland.

Patient cumulative radiation exposure-the potential for unintended consequences.

Several recent publications have sought to highlight the benefits of tracking patient radiation exposure and how it can be used to strengthen the justification and optimization processes to enhance patient safety. In some cases, authors promote the use of dose tracking to keep medical prescribers aware of the patients' cumulative exposure, presumably with a view to influencing the justification process. Inclusion of patient dose history in the justification process can be problematic for reasons that are not always well understood by medical prescribers. Our paper seeks to highlight these issues and attempts to provide some clarification. Key Points • Care must be taken in how cumulative radiation exposure is interpreted as it pertains to the justification process.

Doses under automatic exposure control (AEC) for direct digital radiographic (DDR) X-ray systems.

Current guidelines quote tolerances for automatic exposure control (AEC) device performance for X-ray systems as 'Baseline ± X %'. However, in the situation where a baseline figure has not yet been achieved, as in the case of commissioning assessments, this tolerance is not relevant. The purpose of this work is to provide mean doses for direct digital radiography (DDR) X-ray system, operating in AEC, against which comparisons can be made. Dose measurements have been recorded under AEC operation on 29 DDR detectors from three different manufacturers. Two different testing protocols were examined: (1) water equivalent phantoms in front of the DDR detector and (2) aluminium block at the tube head. The average patient exit dose, using the aluminium block was 4.6 µGy with the antiscatter grid in place and 4.0 µGy with the grid removed. Using the water phantoms, the average dose was measured at 17.1 µGy with the antiscatter grid in place and 5.4 µGy with grid removed. Based on these results, it is clear that different testing configurations significantly impact on the measured dose.

Ethical issues in medico-legal exposures.

The Medical Exposure Directive (MED) 97/43/Euratom defines medico-legal procedures as 'procedures performed for insurance or legal purposes without a medical indication'. The term 'medico-legal exposures' covers a wide range of possible types of exposures, very different in nature, for which the only feature in common is the fact that the main reason for performing them does not relate directly to the health of the individual being exposed to ionising radiation. The key issue in medico-legal exposures is justification. Balancing the advantages and disadvantages of such exposures is complex because not only can these be difficult to quantify and hence compare, but often the advantage may be to society whereas the disadvantage is usually to an individual. This adds an additional layer of ethical complexity to the problem and one, which requires input from a number of sources beyond the established radiation protection community. Because medico-legal exposures are considered to be medical exposures, they are not subject to dose limits. In medico-legal exposures where the benefit is not necessarily to the individual undergoing the exposure, the question must be asked as to whether or not this is an appropriate framework within which to conduct such exposures. This paper looks at the current situation in Europe, highlighting some of the particular problems that have arisen, and tries to identify the areas, which require further clarification and guidance.