University of California, San Francisco
San Francisco, CA
Abstract Title:
Program Director: Stephen Lazarus, MD
Associate Program Director: Lori Leard, MD
Type of Program: Division of Pulmonary and Critical Care Medicine
Abstract Authors: Susan Pasnick MD, Maggie Hayes BS, Michael Salvaggio MS, Lorriana E. Leard MD, Mary Ellen Kleinhenz MD
RATIONALE
Fluoroscopy is routinely utilized at our institution for transbronchial biopsies performed during flexible bronchoscopy. The health risks of radiation exposure are thought to follow a linear, non-threshold, doseresponse pattern. Best practice is to minimize radiation exposure to the extent possible. Many factors determine radiation dose during fluoroscopy procedures, including patient-to-image intensifier distance, fluoroscopy time, miliamperage and kilovoltage. The fluoroscopy suite at our institution utilizes an Automatic Brightness Control system which automatically adjusts many of these factors. Therefore, we targeted fluoroscopy time as an operator-dependent metric with the aim of reducing total radiation exposure.
OBJECTIVE
To implement educational and systems-based interventions with the goal of completing 80% of fluoro-guided bronchoscopic procedures with under 3 minutes of fluoroscopy time.
METHODS
We collected 1 month of baseline pilot data, including total fluoroscopy time and total radiation exposure for each fluoro-guided bronchoscopic procedure. Then we implemented two interventions. First, the bronchoscopy report template was changed to include mandatory entry of total fluoroscopy time and total radiation exposure. Second, we developed an interactive fluoroscopy teaching workshop for the first-year pulmonary fellows as part of their introductory curriculum. We increased awareness via announcements in the division newsletter and targeted e-mails. For data collection, a monthly report is generated which includes all bronchoscopic procedures during which fluoroscopy is used. By chart review, total fluoro time, total radiation exposure, and complications are collected for each procedure.
RESULTS
During the pilot period, 76% (16/21) of procedures were performed with <3 minutes of radiation time. The mean radiation dose was 764 microgrey (mGy). During the first 5 months post-interventions, 79% (104/132) of procedures were performed with <3 minutes of radiation time (p-value 0.52) with a mean radiation dose of 389 mGy (p-value <0.01). As a result of increased fluoroscopy awareness and education, additional changes in practice (particularly related to frame rates and collimation) have led to a significant decrease in total radiation exposure. Notably, during the last month of data collection, the mean radiation exposure was 177 mGy with 71% (22/31) of procedures having <200 mGy of radiation exposure. This is compared to 15% (3/20) of procedures with <200 mGy of radiation during the pilot period. There have been 2 complications (1 incidence of hemoptysis requiring hospitalization, 1 pneumothorax requiring chest tube placement) in the post-intervention period, which is consistent with our historical rate as well as with the published rate of complications from bronchoscopy procedures with transbronchial biopsies.
CONCLUSIONS
Thus, our quality improvement interventions aimed at reducing total fluoroscopy time have led to improved fluoroscopy awareness and resulted in a significant decrease in total radiation exposure. The reduction in total radiation exposure has important implications for not only the patients, but also for the health care professionals with repeated exposure during procedures. Additional study will be required to assess whether this change in exposure is sustained.
