Watching out for the youngest patients
Three physician specialty groups have made recommendations to avoid the use of CT scans in children for certain conditions. Those recommendations are part of the medical profession’s Choosing Wisely campaign, which has sought to reduce the use of imaging and exposure to radiation and encourage use of alternative imaging methods.
Other areas of concern for pediatric patient safety are electronic health records and use of adult-sized equipment for smaller pediatric patients.
Children generally are more sensitive than adults to the effects of ionizing radiation. Pediatric patients with chronic diseases who undergo multiple CT scans as part of their treatment regimen may be at risk for cancers later in life. A recent study estimated that the 4 million CT scans performed on children each year could result in 5,000 future cancer diagnoses.
Some experts say that even with the increased awareness among providers of the risk of CT scans, there has been little change in clinical practices at hospitals. Utilization of imaging has declined over the past five years or so, but questions remain about whether hospitals are optimizing radiation dose when patients do undergo CT scans.
“Awareness itself doesn’t translate into improvement in practice,” said Dr. Rebecca Smith-Bindman, director of the Radiology Outcomes Research Lab at the University of California, San Francisco. “Variation remains a considerable problem.”
This was one reason why the ECRI Institute placed CT radiation exposure in pediatric patients on its top 10 technology hazards list. Two of the 10 hazards on ECRI’s list relate to medical technologies used to treat children. The institute also cited risks to pediatric patients from adult technologies, which could include electronic health records that have not been configured to support pediatric-specific data, as well as use of adult medical devices when a smaller, child-sized model is not available.
Top 10 tech hazards
2. Infusion pump medication errors: Infusion devices are the subject of more adverse incident reports to the FDA than any other medical technology. Reports submitted to the FDA from 2005 through 2009 include 710 deaths.
3. CT radiation exposures in pediatric patients: Retrospective studies being published indicate an increased risk of future cancers for children exposed to CT.
4. Data integrity failures in EHRs and other health IT systems: Reports show numerous ways that data integrity can be compromised, resulting in the presence of incomplete, inaccurate or out-of-date information.
5. Occupational radiation hazards in hybrid ORs: While radiology department and cath lab staffs are generally well versed in the risks and safety precautions, clinicians working in less controlled environments may be at greater risk for radiation exposures.
6. Inadequate reprocessing of endoscopes and surgical instruments: Flexible endoscopes, with narrow, hard-to-clean channels, can be particularly challenging devices to decontaminate.
7. Neglecting change management for networked devices and systems: Planned and proactive changes to one device or system have adversely affected other networked medical devices and systems.
8. Risks to pediatric patients from “adult” technologies: Because of their smaller size and ongoing physiological changes, children may suffer adverse effects when subjected to adult-oriented healthcare techniques.
9. Robotic surgery complications due to insufficient training: Pressure to use robot-assisted surgical procedures without adequate consideration of the surgical team’s proficiency has contributed to patient complications.
10. Retained devices and unretrieved fragments: A recently published analysis of 9,744 paid malpractice settlements and judgments associated with surgical “never events” from 1990 to 2010 found that, of the four surgical event types studied, nearly half of the incidents involved the retention of a surgical item.
Source: ECRI Institute
Radiologists for several years have focused on reducing radiation doses and inappropriate utilization at a time when CT utilization rates have leveled off. While CT utilization in children 5 to 14 years old nearly tripled at six health systems from 1996 to 2005, usage rates declined from 2008 to 2010.
Two fairly recent efforts—the Alliance for Radiation Safety in Pediatric Imaging’s Image Gently initiative and the Choosing Wisely campaign—have raised awareness about the risks of radiation exposure in both children and adults.
Clinicians are being more cautious about ordering inappropriate CT scans, but many patients continue to receive CT scans even when alternative modalities with lower radiation exposure such as MRI or ultrasound are available. CT scans generally deliver the highest doses of radiation.
Boston Children’s Hospital uses MRI as the primary imaging modality for patients with Crohn’s disease and those with suspected ventriculo-peritoneal shunt malfunctions. It previously used CT scans for those conditions. “We’re really almost a mirror image of how we imaged 10 years ago,” said Dr. Michael Callahan, director of computed tomography at the 395-bed children’s hospital.
Another concern ECRI raised is that few providers share information about previous CT and imaging studies, which can lead to duplicate scans, higher costs and increased patient exposure to radiation. This is likely to become less of a problem, however, as more health systems and hospitals begin to use image-sharing networks that are part of health information exchanges. They also are using picture archiving communications systems known as PACS that allow providers to share images across hospitals and regions.
“It all boils down to having a good understanding of the history for that child, especially if they are coming from a different healthcare institution,” Keller said.
ECRI recommends that hospitals implement checklists or protocols that notify providers when alternative imaging methods should be used or if previous scans are available. UCSF’s Smith-Bindman said, however, that many hospitals have not implemented programs that assess usage and seek to standardize imaging. In addition, few hospitals collect data about CT utilization and dosage that can be used to identify outliers and generate benchmarks.
40% drop in radiation
“You can really have an impact,” Smith-Bindman said.
Keller and other experts say children’s hospitals are more likely to be leaders in reducing CT radiation exposure in pediatric patients and ensuring that the right supplies and medical devices are being used in the treatment of children. Six children’s hospitals—Boston Children’s, Children’s Hospital of Philadelphia, Cincinnati Children’s Hospital Medical Center, Duke University Medical Center in Durham, N.C., Massachusetts General Hospital, Boston, and Primary Children’s Hospital in Salt Lake City—have formed a coalition to develop best practices for optimal CT scans and a dose index based on the size of the patient and common medical indications, such as appendicitis.
“We want to lower doses in studies that are performed frequently,” Callahan said.
In hospitals that treat adult and pediatric patients, there may be less attention to the specific needs of children, these experts say.
“Pediatric hospitals have the advantage of focusing solely on the pediatric patients,” Keller said. Hospitals that treat adults and children “have such a broad population (that) the pediatric needs can slip through the cracks.”
The fast-moving adoption of electronic health records also may present challenges specific to pediatric patients. The Agency for Healthcare Research and Quality this year provided a format for EHR developers to understand what information should be included about children in a health record. In some cases, EHRs do not include information about vaccinations or allow height and weight to be viewed on the same screen.
Dr. Davidson Freeman, a pediatrician at Georgia Regents Health System in Augusta, Ga., said his health system’s EHR has been configured to include pediatric options. But some community physicians who are using a different EHR system have had some problems with their own systems, which he described as not “pediatric friendly.”
ECRI also cited the use of adult doses for CT and X-ray and medication dosing errors as other examples of adult technologies that can be a risk to pediatric patients. The institute recommended that clinicians weigh only infants and children in kilograms to further prevent medication dosing errors, use e-prescribing systems that have pediatric-specific medication libraries and consider whether an EHR complies with the AHRQ’s format when making an EHR purchasing decision.
“A continuing trend is definitely tied into the growth of IT-based medical devices and adoption of EHRs in the hospitals,” Keller said. “The rapid adoption of EHRs is a good thing but raises new safety concerns.”
The 2013 ECRI hazards list also focused on how using adult technologies on pediatric patients can impact their care. It noted there are few devices developed to specifically target children, so adult technologies are often the only alternative.
- Establish protocolsfor determining whether an alternative imaging method such as MRI or ultrasound could be used in the place of CT, and standardize protocols for dosing to ensure that children do not receive higher than necessary radiation exposure.
- Participate in image-sharing networksor picture archiving communications systems that can help prevent patients from receiving duplicate scans and reduce the costs of receiving more than one scan.
- Incorporate the concerns of pediatric patientswhen making electronic health records or e-prescribing purchasing decisions.
- Name a pediatric technology safety coordinator who can educate staff about safety considerations and identify which devices and systems can be used with both adults and children.
- Collect datawithin a hospital or health system that can be used to identify outliers and measure utilization for patients undergoing CT scans.
Needs of the patient
“Pediatric-specific devices can be slow to reach the market because the small number of patients available to study, the devices’ high-risk nature and high development costs,” ECRI said in the report. “Thus healthcare providers are often put into the position to use a technology designed for adults to diagnose or treat conditions in children.”
Matthew Maltese, director of biomechanics research at the Children’s Hospital of Philadelphia, and six other research groups in September received $3.5 million in grants aimed at boosting the development and availability of pediatric medical devices. The grants are the third round of funding that the FDA has awarded to support the development of pediatric devices since 2009.
At the Children’s Hospital of Philadelphia, Maltese and other engineers work with clinicians to translate ideas into marketable devices. The grant is expected to support that work, which started Oct. 1.
“There is an unmet need,” Maltese said. “The challenge is that there are barriers to pediatric device development.”
Follow Jaimy Lee on Twitter: @MHjlee