INTRODUCTION
It is well known that medical imaging procedures remain the largest source of man-made exposure to ionizing radiation and continue to grow substantially (Redmond et al., 2020). Radiation from medical procedures produces excess cancer risks depending on many factors, including age and gender (Lin, 2010). The basic task of medical diagnostic radiology is to provide high-quality diagnostic images to plan patient care. Thus, quality assurance (QA) is an important tool in medical imaging procedures. ALARA (As Low As Reasonably Achievable) principle is the basic aim of the QA program and optimization of radiological practice that aims to provide the best possible diagnostic information while keeping the radiation dose to a minimum (Surić Mihić et al., 2008). In today’s modern medicine, a large number of different radiological diagnostic procedures are performed in which patients sometimes receive a significant dose of radiation, and the costs of radiological services regarding the equipment and resources needed are high and rising (Williams et al., 2007; Amorosa et al., 2013; Sulieman et al., 2017).
Assessing the quality of radiographic images is essential for precise diagnosis. The two primary methods for evaluating image quality are objective assessment and subjective assessment. Subjective assessment, carried out by technologists and radiologists, depends on the radiologists’ experience and training to appraise the picture. The primary variables considered in the subjective evaluation were the visibility of anatomic features and the general quality of the picture in terms of brightness, contrast, sharpness, and artifacts. Medical physicists use objective assessment, which uses quantitative measures to quantify certain aspects of images: resolution, contrast-to-noise ratio, and signal-to-noise ratio. Although both subjective and objective evaluations have merit, they are not without restrictions. While quantitative measures may not always capture all vital information for diagnosis, subjective evaluation is subject to variation across radiologists. The best method for thoroughly assessing radiographic image quality is to combine the two methods (Lau et al., 2004; Babikir et al., 2015). The imperative of establishing and implementing a QA program includes not only fulfilling the requirements on the technical performances of the equipment but also the optimum use of the equipment and other resources. Primarily monitoring of patient doses received during radiological diagnostic examinations and reject analysis. Given that the poor quality of radiological diagnostic images, which often results in repetition of radiographs, is the major cause of unnecessary patient exposure, the main components of the QA program are the evaluation of image quality and identifying the cause of poor quality images and the determination of doses that patients receive in particular diagnostic procedures (Williams et al., 2007; Surić Mihić et al., 2008; Inkoom et al., 2009; Arbese et al., 2018). The emergency department is usually a very busy department and requires quick action from staff. Working in a busy environment might lead to reducing awareness among staff regarding patient radiation protection and standard image quality parameters. Emergency professionals are dedicated to providing the highest quality of emergency care to all patients in a safe and timely manner. Radiological technologists in the emergency department are devoted to providing the highest quality of patient care. It is expected that diagnosable findings with high image quality are achieved for all patients in a safe environment. Because the emergency department is always overcrowded with patients and relatives, it presents a greater challenge for radiological technologist to perform safe radiology procedures and achieve high image quality in the emergency department. The American College of Radiology (ACR) provides guidelines to assist in providing appropriate radiologic care for patients. It is based on current knowledge, available resources, and the needs of the patient. Previous studies reported that patients’ effective doses for the extremities and chest X-ray procedures range from 0.1 to 0.2 mSv (Lanhede et al., 2002; Yarmohammadian et al., 2017; Elshami et al., 2019). The dose is a function of the examined organ, patient weight, and machine setting. Computed tomography (CT) provides better image quality with higher radiation doses. The dose in the emergency department’s CT ranges from 2.0 to 10 mSv per procedure. The patient’s dose depends on the imaging technique, clinical indications, and the patient’s weight. The patient’s dose is minimized by proper justification and optimization of the examinations for disabled and nondisabled patient groups. Therefore, assessment of patients’ doses is recommended to reduce the patients’ doses and the related risks while maintaining the image quality (Günalp et al., 2014; Khlafallah, 2015; Abuzaid et al., 2019).
The main objective of the ACR guidelines is to provide a framework to deliver effective and safe medical care (Arbese et al., 2018). In Saudi Arabia, radiological technologist and medical teams are multinational; therefore, the practice may vary from one department to another. In Saudi Arabia, limited information is available for patient management at the emergency department. The current study aims to evaluate the radiographic image quality and patient safety at emergency departments at the Saudi Ministry of Health hospitals in Riyadh based on the ACR guidelines.
METHODS
Patient data collection
This study consisted of two phases. Phase 1 assessed the quality of the radiological imaging procedures done at the emergency departments, while Phase 2 assessed the radiation safety measures. Data were collected from two emergency departments equipped with digital X-ray systems.
Imaging protocol
Radiological imaging plays a vital role in the rapid and accurate diagnosis of injuries in trauma patients. The imaging protocols employed in radiology departments for trauma patients depend on the mechanism of injury and clinical presentation; plain X-rays with two projections, anteroposterior and lateral, are used for standard cases. Additional projections may be needed depending on the trauma and patient conditions. Because, for trauma patients, time is a critical tool in trauma management, quick decision for additional projections is vital to improve diagnostic findings.
Phase 1: image quality
Image quality was evaluated using a score sheet that represents certain clinical criteria to define the quality of the image. The basic criteria employed during the assessment of the radiographic image quality are shown in Table 1. Three experienced radiologists evaluated the image quality, and the average score was calculated for each image.
Image quality score sheet.
| Image criteria | Degree of visibility | Score |
|---|---|---|
| Visualization of characteristic features | Feature detected and fully reproduced | 1 |
| Feature just observable | 2 | |
| Feature not observable | 3 | |
| Reproduction of anatomical structures | Details detectable and clearly defined | 1 |
| Feature just detectable | 2 | |
| Details not observable | 3 | |
| Visually sharp reproduction | Details clearly defined | 1 |
| Details just clear | 2 | |
| Details not clear | 3 |
Phase 2: radiation safety measures
A survey was sent to all radiography staff working in the emergency departments to evaluate their qualifications and experiences in emergency departments. Also, their opinion regarding patient safety and protection measures at the emergency department was explored. All participants filled a consent form before submitting the survey. Also, they were informed about their right to withdraw from the study at any point without consequences.
Data analysis
The results of this study were statistically analyzed using SPSS version 23 (IBM SPSS Statistics for Windows, IBM Corp, Armonk, NY, USA). Results are presented as percentages and mean ± standard deviation, and the range of the readings is given in parenthesis. Figures and tables were generated using Microsoft Excel.
RESULTS
A total of 55 procedures were included in the study (Table 2). Table 3 presents the average patient age and imaging parameters. The results showed that 31-43% of the images had high image quality and a “high diagnostic value,” while 5-25% of the images had poor image quality and a “low diagnostic value” (Table 4). Most of the staff are male and senior specialists, working at CT and general radiography (Table 5). Figure 1 shows that 20% of the staff hold a master’s degree, and 62% of the staff hold a BSc degree. It is also noted that the majority of staff have pursued their academic education in Saudi Arabia (85%). The majority of staff have reasonable experiences in the emergency radiology department and medical imaging in general (Fig. 2). Table 6 shows the results of staff opinion regarding safety and radiation protection measures in the emergency department. The results showed that 50% believe that the current measures of radiation safety are unacceptable.
Clinical indications of the radiographic procedures.
| Clinical indication | No. of procedures | % |
|---|---|---|
| Foot | 7 | 12.7 |
| Cervical spine | 5 | 9.1 |
| Skull | 6 | 10 |
| Hand | 6 | 10 |
| Chest | 13 | 23 |
| Knee joint | 7 | 12.7 |
| Ankle | 5 | 9.1 |
| Clavicle | 1 | 1.8 |
| Pelvis | 3 | 5.6 |
| Lumbar spine | 6 | 10 |
| Total | 55 | 100 |
Patient age and image acquisition parameters.
| No. of patients | Patient age (years) | Tube voltage (kVp) | Tube current–time product (mAs) | Time (ms) | FFD (cm) | |
|---|---|---|---|---|---|---|
| Chest | Others | |||||
| 55 | 25.8 ± 16 (1.0-65.0) | 73.7 ± 19 (55.0-120.0) | 7.0 ± 9 (0.3-53.0) | 19.2 ± 19 (3.0-06.0) | 180 | 120 |
Abbreviation: FFD, film-focus distance.
Assessment of the quality of radiographic images.
| Image criteria | Degree of visibility | Score | Achieved score | % |
|---|---|---|---|---|
| Visualization of characteristic features | Feature detected and fully reproduced | 1 | 24 | 43.6 |
| Feature just observable | 2 | 17 | 30.9 | |
| Feature not observable | 3 | 14 | 25.5 | |
| Reproduction of anatomical structures | Details detectable and clearly defined | 1 | 22 | 40.0 |
| Feature just detectable | 2 | 30 | 54.5 | |
| Details not observable | 3 | 3 | 5.5 | |
| Visually sharp reproduction | Details clearly defined | 1 | 17 | 30.9 |
| Details just clear | 2 | 29 | 52.7 | |
| Details not clear | 3 | 9 | 16.4 |
Demographic data of the staff.
| Gender | Current position | Area of practice | |||||
|---|---|---|---|---|---|---|---|
| M | F | Head | Senior | Junior | CT and general radiography | General radiography | |
| N | 28 | 6 | 5 | 13 | 16 | 16 | 18 |
| % | 82 | 18 | 15 | 38 | 47 | 47 | 52 |
Abbreviation: CT, computed tomography.
Safety and protection practice at the emergency department.
| Question | Strongly agree | Agree | Neutral | Disagree | Strongly disagree |
|---|---|---|---|---|---|
| Patient protection and safety tools are available at the emergency department | 9 | 8 | 7 | 5 | 5 |
| 26.47% | 23.53% | 20.59% | 14.71% | 14.71% | |
| Co-patients are well protected against radiation | 10 | 6 | 7 | 3 | 8 |
| 29.41% | 17.65% | 20.59% | 8.82% | 23.53% | |
| Lead aprons are frequently checked and valid | 6 | 7 | 8 | 5 | 8 |
| 17.65% | 20.59% | 23.53% | 14.71% | 23.53% | |
| Infection control measures are employed regularly at the emergency department | 4 | 6 | 7 | 6 | 11 |
| 11.76% | 17.65% | 20.59% | 17.65% | 32.35% | |
| Radiologist are aware of the radiation protection measures | 3 | 6 | 8 | 4 | 13 |
| 8.82% | 17.65% | 23.53% | 11.76% | 38.24% | |
| Staff are using radiation detectors for occupational exposure | 6 | 5 | 8 | 5 | 10 |
| 17.65% | 14.71% | 23.53% | 14.71% | 29.41% | |
| X-ray machines are calibrated regularly | 6 | 6 | 8 | 3 | 11 |
| 17.65% | 17.65% | 23.53% | 8.82% | 32.35% | |
| Are you satisfied with the current performance of the department | 6 | 5 | 6 | 9 | 8 |
| 17.65% | 14.71% | 17.65% | 26.47% | 23.53% |
DISCUSSION
Radiation safety and image quality in the emergency department are very important factors to reduce the radiation risk and to maximize the benefit of the diagnostic findings. The benefit of radiation exposure can be increased by reducing variability in practice and performing each step in clinical care with high reliability. All the procedures performed during the study period are simple procedures with standard exposure parameters. The current study illustrated that image acquisition parameters were within the expected values. The image quality evaluation showed that almost 31-50% of the images had high image quality and high diagnostic findings while the rest of the images had moderate quality or poor diagnostic findings. The reasons for rejection of an image may be due to system errors, exposure factor errors, positioning errors, and failure of patient preparation and instructions before the radiological examination or insufficient clinical information in the request form (Günalp et al., 2014). The current study showed that low diagnostic findings were demonstrated in 5-25% of the images. This is a high rate in digital age systems where system and processing errors are avoidable by using automatic exposure controls (Williams et al., 2007). In conventional radiography, image processing errors contributed to the majority of rejections across departments with film screen radiography systems (Abuzaid et al., 2019). The causes of these errors were related to the lack of sensitivity of the regular processors. On the other hand, errors in exposure factors were due to the absence of technical charts or inaccurate manipulation of factors to fit the patient’s size. Proper selection of exposure factors (kVp and mAs), clear patient preparation, and instructions prior to examinations are the effective methods for reducing rejection rates and improving the radiographic outcome (Khlafallah, 2015). The improvement in image receptor technology provides potential for improving the image quality and reducing rejection rates. Regular implementation of reject analysis with immediate corrective action is essential and should be performed as recommended in the published literature (Khlafallah, 2015; Elshami et al., 2019). Table 4 shows the scores of the visualization of characteristic features rated as feature detected and fully reproduced in 43.6% of the images and feature just observable in 30% of the images, while the rest of the images are unacceptable (25%). The number of poorly scored images that were rated as rejects varied from 5.0% to 25%. Variations in the technologists’ experience might contribute to the quality of the outcome. The standard of radiographs can be maintained at a satisfactory level with good scores through standardization of the technical factors along with staff training as needed (Inkoom et al., 2009; Khlafallah, 2015; Sulieman et al., 2017). When performing radiographic images, patient characteristics and clinical purpose are most important and should be carefully noted in order to produce images with an acceptable diagnostic quality and a reasonable patient radiation dose. It has been reported that less experienced staff make more errors than those with experience (Günalp et al., 2014). Therefore, the technologist must practice at emergency department training under the supervision of a senior technologist. On the other hand, patient conditions at the emergency department may generate additional challenges, particularly for patients who are severely injured. In addition to that, insufficient staffing may generate other challenges since staff are working under time pressure. All the aforementioned problems can affect the image quality and thus diagnosis and treatment (Abuzaid et al., 2019). The qualification of the staff in this department is satisfactory as most of the staff obtained their qualifications from reputable universities. The current study showed unsatisfactory protection and safety measures for patients and workers. It is important to assess the occupational radiation exposure for workers (Khlafallah, 2015) and patients during radiological procedures. Table 7 provides a comparison of patient doses reported in previously published studies. The dose may reach 2 mSv per procedure for the lumbar spine; therefore, precise imaging protocol is needed to ensure limited repetition of projections with optimized radiation exposure while reducing the patient doses (Inkoom et al., 2009; Khlafallah, 2015; Sulieman et al., 2017; Surić Mihić et al., 2008; Williams et al., 2007). Multiple studies emphasized the importance of radiation awareness among radiological technologists (Babikir et al., 2015; Lanhede et al., 2002; Yarmohammadian et al., 2017). Therefore, immediate intervention is required to improve staff and patient safety in the emergency department. The limitation of this study is that the patient and staff doses are not quantified due to the lack of dosimetry systems at the department. Therefore, further study is suggested to assess radiation exposure for patients and workers.
Patients’ effective dose during imaging procedures.
| References | Imaging procedure | Patients’ effective dose (mSv) |
|---|---|---|
| Amorosa et al. (2013); Sulieman et al. (2017) | Chest X-ray (AP) | 0.1-0.2 |
| Lau et al. (2004); Williams et al. (2007); Amorosa et al. (2013) | Lumbar spine X-ray (AP) | 1.0-1.5 |
| Amorosa et al. (2013); Redmond et al. (2020) | Pelvis X-ray (AP) | 1.5-2.0 |
| Amorosa et al. (2013); Redmond et al. (2020) | Cervical spine X-ray (AP and lateral) | 0.3-0.5 |
| Lin (2010); Arbese et al. (2018); Redmond et al. (2020) | Extremity X-ray (AP and lateral) | 0.05-0.1 |
Abbreviation: AP, anteroposterior.
CONCLUSIONS
Patient safety and protection are essential in any radiology department. To balance the required image quality and patient safety with radiation dose to patients, several factors should be considered, including the properties and status of the imaging system, characteristics of patients and anatomical parts to be examined, and elements of the procedural technique. The image quality results were above the acceptable range. Poor radiation safety and protection were reported by staff.