Can a more rigorous approach to justification reduce the number of patient deaths?

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Zoe Brady, PhD.


“This was an extremely unfortunate incident, but it highlights one of the principles of radiation protection: justification,” Brady noted. “Justification is probably the most difficult radiation protection principle to explain and understand in practice.”


People working in medical imaging have a good appreciation of dose optimization and image quality and dose limitation with respect to occupational exposures. “Our working procedures reflect regulatory requirements, but implementation can often be complex,” she explained.


Brady’s recent lecture at the Royal Australian and New Zealand College of Radiologists (RANZCR) Annual Scientific Meeting in Adelaide addressed the issue of rationale rather than anaphylactic reaction. It was based on Victoria’s regulatory requirements (Victorian Radiation Act 2005) for CT scans and a review of the Coroner’s case, which indicated that it is not uncommon for referring practitioners to fail to provide all the items required for a adequate reference.


As a result, a number of Coroner Simon McGregor’s recommendations relate to inappropriate requests, she told AuntMinnieEurope.com.


Circumstances of the patient’s death


Hickey’s voluntary health check on May 1, 2019 was suggested by his employer, Programd Skilled Workforce Limited, as part of the company’s testing scheme for all senior staff after a colleague suffered near cardiac arrest. fatal in 2018.


The mother-of-two had no history of heart problems, but had an anaphylactic reaction to contrast injected as part of CT coronary angiography and she died in hospital eight days later. She had never met or spoken to the physician, Dr. Doumit Saad, who had authorized the insertion of her electronic signature in her referral by a corporate booking service, Priority Care Health Solutions. The medical imaging booking service, MRI Now, used the referral to send Hickey to the Future Medical Imaging Group (FMIG) in Moonee Ponds for the scan.


A radiographer administered the intravenous contrast medium and radiologist Dr. Gavin Tseng was in charge overall. Tseng only saw the patient after she collapsed.



Dr. Gavin Tseng

Dr. Gavin Tseng. Photo courtesy of Paul Jeffers.


According to media reports, Tseng said he didn’t give him potentially life-saving adrenaline, saying he couldn’t do two things at once. During the investigation, it was noted that Tseng had received only general anaphylaxis training and was unaware of any resuscitation instructions posted at the clinic.


Two teams of paramedics treated the patient, with only the second team administering adrenaline, but Hickey suffered multiple organ failure. An autopsy revealed a normal heart and coronary artery and no evidence to suggest a history of symptoms or signs related to cardiovascular disease.


System failures


So how did the deviation from the procedure cause the patient to fail?


The request for a cardiac CT scan and coronary artery calcium scoring was received by a private imaging practice, but the request did not include a clinical note or indication for the scan, Brady said. The review was still conducted despite the workplace radiation management plan, which states that without clinical information, a request should not be granted.


Furthermore, the coroner felt that the referrals from this workplace assessment program were in fact a snap test of Australia’s system of private diagnostic imaging practices, she added. Since the company’s management staff who underwent the cardiac CT scans were located across Australia, these imaging requests were directed to an almost random selection of practices across the country.


Of the 26 referrals, all had insufficient clinical details and follow-up contact information, but each analysis was completed. The coroner said ‘the checks and balances the industry believed were present have failed’.


Vital education


In its response, the RANZCR noted that it has strong standards and guidelines for the practice of clinical radiology and has developed the guideline on iodinated contrast media for clinical radiologists and other healthcare professionals. involved in the administration of iodinated contrast media to ensure patient safety.


Additionally, the College updated the Continuing Professional Development (CPD) requirements effective January 2023 to specify that all clinical radiologists must complete anaphylaxis training once every three years to maintain management skills. anaphylactic reactions and record this training in their CPD. ePortfolio.


In addition, Victoria’s Department of Health, the local radiation regulator, conducted on-site inspections of practices where cardiac CT scans are performed to assess the processes for justifying and approving such scans, according to Brady. .


In terms of understanding legal substantiation requirements, ongoing training such as this type of case review is provided to radiologists at Alfred Hospital, she said. Additionally, she highlighted the problem at the hospital level so that clinicians requesting CT scans understand the issues. This decision also added to the discussion about the use of an evidence-based clinical decision support tool and referrals within the hospital.


She noted that such case reviews are helpful in assessing changes that can be made at the level of practice, as it provides an opportunity and a contemporary context for radiologist education and a refresher of knowledge about the radiologist’s responsibilities during substantiation and approval of CT scans or other diagnostic images that involve exposure to ionizing radiation.


golden rules


Brady said that when individual justification for a CT scan is required, the radiologist should determine if there is a net benefit from the radiotherapy procedure by considering the following:




  • The specific objectives of the procedure

  • The characteristics of the patient concerned

  • The total potential clinical benefits, including direct health benefits to the patient and, if applicable, benefits to society at large

  • The individual harm to the patient that may result from the procedure

  • The state of pregnancy of a patient of childbearing age

  • The effectiveness, benefits and risks of available alternative techniques having the same objectives with less or no exposure to ionizing radiation

  • All available medical data and patient records relevant to the medical exposure


These requirements are set out in the ARPANSA code for radiation protection in the event of medical exposureRPS C-5, 2019. Although this code is not yet a legal requirement in all Australian jurisdictions, it provides the necessary guidance, she said.


“More generally, the importance of justifying diagnostic imaging involving ionizing radiation needs to be further recognized. This tragic case demonstrates the value of ensuring that these processes are in place and implemented,” commented Brady.


Whether Hickey should have undergone the analysis is a complex question. The coroner’s report, however, found the process was riddled with unethical behavior and shortcuts; as Programd Skilled Workforce Ltd, Priority Care Health Solutions, MRI Now and Drs. Saad and Tseng all contributed to Hickey’s death, and that profit was put above patient safety. A civil case is also pending.


The full report and responses from various medical schools in Australia are available on the coroner’s website.


Workload pressures


It’s important to keep in mind the pressures on employed radiologists to perform high volumes of work and perform many different tasks at once, an experienced radiologist told AuntMinnieEurope.com.


To learn from this case, the source believes a situational awareness discussion is essential. Tseng seemed to become obsessed with the patient’s seizure, then the airway, and he couldn’t see or think any wider. Moreover, of the 26 references, none had clinical information: “insufficient” does not show the extent of the problem.


Significantly, the first ambulance team was trained in Advanced Life Support (ALS) and assumed Tseng was in control, so followed his instructions. The second crew was trained in MICA (Mobile Intensive Care), and with that much higher skill set saw the problems and took command, the radiologist said.


Legally, all radiation exposure is supposed to be justified by the risks of radiation being lower than not taking the test, but unfortunately this is often not done in practice, the source continued.


“Substantiation audits must be checked against the medical record because too many referrers bypass the system by writing down ‘clinical’ details that will allow an analysis to be carried out, even if it is not really about the patient’s symptoms or a true differential diagnosis. The education of referents is also necessary.”

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