patient management, equipment planning and safety ...€¦ · patient management, equipment...

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Patient Management, Equipment Planning and Safety Considerations

Adjunct Assistant Professor (Radiology) The George Washington University

School of Medicine and Health Sciences, Washington DC, USA

Past-Chair, IUPESM Health Technology Task Group President, HPS Medical Health Physics Section

Chair, AAPM International Educational Activities Committee

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Planning of Medical Imaging Services

▲  According to the levels of health care

▲  Categorized based upon their complexity

▲  Analysis of morbidity and mortality in the community

▲  Review of utilization patterns of the various radiological procedures

▲  Technological harmonization regarding complexity

▲  Coordination between health services

1996

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“Defining the Medical Imaging

Requirements of a Health Station”

2011 ICMP, Brazil

2017

Part I: Medical and Public Health Needs of a Rural Health Center

Health conditions that may require imaging a.  Chest diseases: viral and bacterial infections such as

tuberculosis b.   Trauma c.  Degenerative diseases of the musculoskeletal system d.   Acute abdominal pain, diarrhea, blunt abdominal

trauma e.  Kidney stones f.  Pregnancy g.  Gynecological problems.

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C. Borrás (ed.), Defining the Medical Imaging Requirements for a Rural Health Center, 2017

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Fig. 2.7 a Oblique transparent line of fracture in the third proximal phalange of the left hand, as it can be seen in AP and oblique views (white arrows).

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Fig. 2.9 Acute cholecystitis. Echogenic image (gallbladder stone) with acoustic shadow (white arrow) and wall bladder thickness of 5 mm (black arrow)

The clinical practitioner in a rural health center must

▲  Know the normal images of the examined anatomical region, and thus, be able to detect when an abnormality is present even though he/she may not be able to reach a diagnosis

▲  Decide whether to refer the patient to a higher health care level or not

▲  Describe the image accurately in case the consulting imaging specialist is not able to visualize it

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FOR THIS, TRAINING AND EXPERIENCE IS PARAMOUNT


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Part II: Medical Imaging Modalities The medical imaging technologies need to be justified

by the overall benefits achieved in terms of safety, health outcomes and costs, and need to be tailored to

the specific health needs to be addressed.

Medical imaging technologies should be:

a.  Integrated into the national healthcare system b.   Regulated according to international standards c.  Appropriate to the level of the healthcare system d.   Appropriate to the therapy capabilities available.

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10 http://www.who.int/medical_devices/Sun_am_INN_5_SCHONENBERGER.pdf?ua=1

Medical Imaging Equipment (Hardware and Software) in a Rural Health Center ▲  Ultrasound Units (Fixed or Mobile) with Probes ▲  X-Ray Systems with Detectors and Processors

(analog or digital) ▲  View boxes (if film is used) ▲  Peripherals and Supplies ▲  Workstations (if CR/DR is used) and/or PCs for

•  Image Display •  Image Storage and Retrieval •  Teleimaging

▲  Telephone Network and Internet Access 11

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The ultrasound unit should be an all-purpose general ultrasound scanner mainly for abdominal work with Doppler capability and digital output.

Ultrasound Transducers (Probes)

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14 C. Borrás (ed.), Defining the Medical Imaging Requirements for a Rural Health Center, 2017

Fig. 5.2 Hand held wireless probe—connects to a tablet PC or a Smartphone with software

[11]

Fig. 5.3 The $50 ultrasound probe developed by Newcastle University,

UK [12]

Fig. 5.4 Image of a gall bladder

from a high-end scanner (left) and that using the low cost probe (right)

[12]

PAHO / WHO’s Basic Radiologic

System (BRS) (1975) WHO Health Imaging

System – Rad (WHIS-RAD 1995 - …)

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WHIS - RAD

Upda%ngtheWHIS-RAD(2014)

www.GlobalDiagnos%X.org

ENERGYReserve

DIGITALdetector

DICOMViewer&PACS

Ultra-robustMECHANICS

Tele-radiologyTele-maintenance

IntegratedTUTORIALS&Posi%oningGuide

TargetUSD.50,000incl.10-yearmaintenance

Rugged&Versa%lePOWERSUPPLY

2015: The GlobalDiagnostiX prototype, the outcome of four

years of research and innovation through an alliance of 35

researchers across Switzerland and Cameroon, is ready!

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Will this new system succeed? The BRS and the WHIS-RAD were felt inferior by many countries because they did not have FDA clearance. And in some facilities where it was installed, the systems ceased to function because the x-ray operators lacked education and training.

Part III: Planning a Medical Imaging Unit – Equipment Procurement

▲  New or used – Refurbished? ▲  Donation or purchase ▲  Payment facilities ▲  Warranties / Maintenance (Downtime) ▲  Accessories / Replacement parts ▲  Manuals (service and operation) ▲  Permits / Regulations ▲  Time line ▲  Development / Review Technical Specifications

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Part III: Planning a Medical Imaging Unit – Physical Infrastructure

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▲  The room that will house X-ray equipment must be shielded taking into account the workload, the location and orientation of the unit in the room and the potential occupancy of adjacent areas, including those above and below.

▲  The placement of the patients’ waiting room should be chosen in order to optimize the shielding.

▲  If there is film processing, the film storage area must also be shielded.

▲  Locally available materials should be considered for shielding to replace lead


▲  To obtain patient images and record areas of clinical interest, including potential pathology

▲  To perform basic maintenance for both ultrasound and X-ray equipment and to communicate with service technicians off-site

▲  To send images to the consulting clinician and decide examination outcome

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Part III: Planning a Medical Imaging Unit – Technical Staff Capabilities


Part III: Teleimaging and Networking

▲  Different bandwidths required for •  Still images (US & X-Ray) •  Live video streaming (US) •  ‘ Store and forward’ image transfer (US & X-Ray)

▲  PC and DVD burner needed for image storage ▲  Image transmission requires compression ▲  JPEG image quality OK? ▲  For X-ray, CR better than digitizing film ▲  The role of the cellular telephone and network


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Part III: Teleimaging and Networking

To ensure compliance with radiation safety requirements, each rural health center should designate a person among its staff that will function as the “radiation safety officer (RSO)”

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Part III: Planning a Medical Imaging Unit – Radiation Safety


2014

IBSS

▲  Ancillary shielding •  Leaded aprons •  Gonadal and thyroid shields

▲  Radiation dosimeters for workers ▲  Dose reduction techniques for patients ▲  Staff training – ESSENTIAL ▲  Outside consultants – Needed

•  Periodically on site •  Via telephone and Internet

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Part III: Planning a Medical Imaging Unit – RSO Responsibilities

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3.15. Registrants and licensees: (i) Shall ensure that adequate maintenance, testing and servicing are carried out as necessary so that sources* remain capable of fulfilling their design requirements for protection and safety throughout their lifetime;

IBSS

* Includes equipment

EBSS

Annex IX: Indicative list of information for licence applications

(g) Maintenance, testing, inspection and servicing so as to ensure that the radiation source and the facility continue to meet the design requirements, operational limits and conditions of operation throughout their lifetime.

Maintenance Issues ▲  Before imaging equipment is acquired:

•  Its operation and maintenance should be ensured ▲  Full maintenance of X-ray and ultrasound

equipment is best done by specially trained personal. •  Corrective vs Preventive Maintenance •  Maintenance Contract

▲  Minor repairs can be done locally •  Changing fuses •  Mechanical cleaning/lubricating •  Measuring the mains power supply

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Need for QA/QC and Professional Development Program

▲  A medical imaging service cannot function without an adequate Quality Assurance / Quality Control (QA/QC) program), which periodically tests equipment performance and encompasses radiation protection and maintenance issues

▲  Equally essential is the periodic training update of clinical and technical staff, especially regarding information technology

▲  The tasks may be contracted outside, but the rural health center manager should assume responsibility and assign coordination roles to his/her staff.


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