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Record Books and Score Cards. (You Cannot Tell the Players Without a Score Card)

The article “Patient Exposure to X-rays During Coronary Angiography and Percutaneous Transluminal Coronary Intervention—Results of a Multicenter National Survey” published in this issue of CCI [1] provides a French nationwide look at clinical radiation use presents a large dataset (sport record book) that facilities could use to benchmark their own radiation use (game score card) as part of their quality process. Only 44 of 76 invited centers contributed data during the 2010 study year. The reasons for nonavailability are discussed in the article. Beyond this study, several additional multicenter datasets are available from the IAEA, the United States [2], and other countries. Existing published data provides an initial reasonable benchmark for a facility level radiation management QA/QI program. However, there is no United States national record book. A meaningful and reliable United States radiation data base for interventional cardiology does not exist in 2014. Much of the available US case data only includes fluoroscopic time. This is understandable because cardiologists have over relied on fluoroscopic time as the only dose metric [3]. Unfortunately, fluoro time does not provide any indication of the effects of patient size or cine on radiation use. Indeed, there are anecdotal reports of cardiologists completing procedures using only cine to avoid certain state regulatory reporting requirements based on fluoro time (1 min of cine1⁄4 10–20 min of fluoro). Other essential parameters, such as the cumulative reference point air kerma, were either not collected or have not been extensively published. Gorges et al. [1] paper [1] reports reference point air kerma, but does not report statistics for this quantity in the abstract, presumably because data was only available from some sites. Recording and tracking reference point air kerma (mGy on most systems) is needed if there is any concern about skin injuries. A complete set of the data needed to adequately document radiation use in individual procedures is provided by all modern fluoroscopes and is increasingly available in detail in structured dose reports. Fluoroscopic equipment QA needs to include verification of the accuracy of this data. A task force of the American Association of Physicists in Medicine (AAPM) is currently finalizing a protocol that is likely to be acceptable to equipment manufacturers. Improved workflows are needed to collect radiation data locally and consolidate this information into an accessible national repository. Facilities must implement a process to analyze their own collected data against standards and then use their findings for process improvement. Sample processes for facility use of radiation data as part of QA/QI have been published [4]. Even without automation, it is strongly recommended to insert key dosimetric values (e.g., fluoro time, cumulative reference point air kerma, and kerma area product) into each and every case report [4,5]. Signing for the delivered radiation dose provides immediate feedback to the operator and is accessible if necessary for later review. Signing signifies that the operator is aware of the radiation used for that procedure. Similar reporting is common for contrast and medication use. Automated data reporting will simplify getting the data onto the report and provide better computerized radiation dose access for the QA/QI process. Even when automation is in place, operator radiation awareness is improved if the data is part of the signed clinical report.