Addressing mobile neonatal image quality through an educational programme

Abstract

The World Health Organization has given special attention within its recommendations to the restriction of radiological diagnostic procedures on children. Should a neonatal examination be done, the use of special lead shielding devices and correct radiographic techniques is essential. The Alliance for Radiation Safety in Pediatric Imaging (ARSPI) and the Conference of Radiation Control Program Directors (CRCPD), founding bodies of the “Image Gently” campaign promote additional training to ensure that patients receive a timely and optimal imaging examination with the lowest amount of radiation. The primary goal of diagnostic radiographers working in the neonatal intensive care unit (NICU) is to produce an image of optimal quality using an optimal exposure technique without repeating exposures, so as to keep the neonatal radiation dose to a minimum. Thus the main concern in this study was whether radiographers were producing optimal quality chest images and if not, whether additional training could assist radiographers to reach this goal in the Free State province of South Africa. This question was addressed by a study comprising three phases. First, the neonatal chest image quality was determined in the NICU by means of a checklist based on and compiled from guidelines in the literature on image quality. This checklist was tested with a pilot study and adjusted as necessary. The researcher evaluated 450 images, selected through simple random sampling. The results of this phase showed that image quality areas required improvement because radiation shielding was absent on 98.7% of images, and collimation absent in 74.9% of images. These results indicated that, for 74.9% of images, four sided collimation was not visible on the image, and there was a probability of 98.7% that such an image had been taken without radiation protection. In addition, lead markers were not utilised in the production of 66.4% of images. The second phase of the study entailed the design and presentation of an educational programme. The educational sessions were based on the evaluation criteria of the checklist as well as image quality areas identified in Phase 1 as needing enhancement. The educational sessions also referred to positioning techniques that should be applied to ensure optimal image quality as specified by the evaluation criteria in the checklist. After the presentation of the educational programme, participating radiographers commented on the programme by completing an evaluation form. Radiographers rated the educational programme as excellent by 96.4%. A small number of participating radiographers (15 of 56 participants) suggested adjustments to the educational programme. The additional information requested by the participating radiographers related to pathology appearances and exposure index recorded on the image. The final phase entailed the assessment of 450 neonatal chest images produced after the educational programme in the NICU, using the same checklist. These images were selected through purposive sampling. Only neonatal chest images produced by participating radiographers that completed the educational programme were included in this phase. The purpose of this evaluation was to establish whether the image quality had improved after delivery of the educational programme. In general, the results from this phase showed strong similarities to the results obtained from the first phase. However, in some areas there was significant improvement of image quality, among which a reduction in electrocardiogram (ECG) lines superimposed on chest anatomy (61.9% in Phase 1 to 41.8% in Phase 3), a tendency to centre closer to thoracic vertebra four, and visible four-sided collimation on images (ρ-value 0.002, Chi-Square test). Image quality areas with no significant enhancement were the absence of lead markers (absent on 63.1% images in Phase 3) as well as the absence of radiation shielding (absent on 98.9% of images in Phase 3). The study, through its educational programme, had a positive effect on the following aspects of neonatal chest image quality: collimation, centring points, and visibility of artifacts (ECG lines). Neonatal chest image quality aspects that require further improvement include lead markers and lead shielding. The study has shown that an educational programme has the potential to improve neonatal chest image quality, which aligns well with the main concerns of the Image Gently campaign. The checklist that was designed can assist radiographers in future evaluations of neonatal radiographic image quality. A neonatal quality control audit programme can be implemented to encourage participation of nursing staff, referring physicians and radiographers with the purpose to address neonatal mobile chest image quality while optimising the radiation dose.