Cardiac cath labs can achieve significant radiation dose reductions through focused, collaborative quality improvement (QI) efforts, according to a new analysis published in Circulation: Cardiovascular Interventions. The authors shared their own experience working with pediatric academic medical centers, noting that other institutions could chart a similar path and make a lasting impact.
“With the development of innovative technologies and the shift from diagnostic cases and isolated interventions to complex interventions performed in the cardiac catheterization laboratory, the importance of radiation dose reduction is magnified,” wrote Brian P. Quinn, MD, Boston Children’s Hospital, and colleagues. “Single institutional efforts over the past 10 years and the field’s focus on QI have made significant strides in cultivating awareness around radiation safety and reducing patient radiation exposure. However, collaborative efforts to lower radiation exposure remain limited with minimal literature reporting how radiation reduction outcomes were achieved.”
Quinn et al. launched the C3PO-QI (Congenital Cardiac Catheterization Project on Outcomes – Quality Improvement) initiative, a multicenter effort to reduce radiation doses across all participating institutions. The initiative began with a meeting, allowing participants to gather and discuss what they hoped to achieve. That group agreed on six key ways to reduce radiation at pediatric cath labs:
- Providing tools for measurement
- Establishing QI processes
- Ensuring proper education for all staff
- Optimizing operator techniques
- Optimizing equipment use
- Pursuing dialogues with vendors
With those key drivers in place, the C3PO-Q1 website was developed, going live in January 2014. Other cath labs were then recruited, and “complete data entry” began by the beginning of 2015 for most participants.
“Concurrently with the C3PO-QI website launch, collaborative QI interventions to reduce radiation doses in pediatric cardiac catheterization laboratories were initiated at C3PO-QI participating institutions,” the authors wrote. “Due to the multi-institutional and longitudinal nature of this project, catheterization cases were done across a broad distribution of equipment manufacturers and equipment ages, with varied numbers of institutional catheterization laboratories in operation and differing institution-specific practices regarding catheterization procedural staffing and radiation use practices.”
The QI measures implemented by the group included facilitating the use of “on-demand static and dynamic reporting tools,” sharing and applying new techniques according to the “Plan, Do, Study and Act” methodology,” holding regular meetings, delivering educational webinars, sharing optimal default equipment settings and much more. Collaborations also occurred with vendors, allowing all institutions to stay informed when it came to recommended techniques.
“Due to the technical programming required to change any catheterization equipment specifications for pediatrics, efforts to customize image settings often need to include manufacturer technicians,” the authors explained. “Within the C3PO-QI collaborative, equipment tips were shared among centers with similar equipment, which allowed sites to work with manufacturers to customize settings and optimize equipment utilization based on shared experiences.”
All data from participating institutions was prospectively collected from Jan. 1, 2015, to Dec. 31, 2017. If an institution failed to capture all applicable data, its data was excluded altogether from this specific analysis. Eight centers in total contributed to the dataset.
Overall, the study’s authors explored data from more than 15,000 cases. Radiation dose was reported as a median and average DAP/kg.
In 63% of all cases, the patient was between the ages of 1 and 18 years old. Another 25% of the cases involved a patient younger than one, and 11% involved a patient over the age of 18.
The team observed that, collectively, median radiation exposure was decreased by 30% for all procedures. All participating sites saw improvements in radiation dose over time.
“Across all cardiac catheterization procedures, we observed substantial radiation dose reductions and changes in practices over time that can be modeled to other pediatric cardiac catheterization labs,” the authors concluded. “These decreases were seen as targeted QI initiatives were pursued at participating C3PO-QI centers and were achieved despite varying institutional radiation baselines, equipment, and practices. Similar QI radiation dose reduction methodologies, targeted to a specific procedure or procedure type, could be attempted at other institutions performing cardiac catheterization procedures for congenital heart disease to improve patient safety overall.”