Neonatal Med.  2024 Nov;31(3):56-64. 10.5385/nm.2024.31.3.56.

Minimizing Radiation Exposure in Neonatal Intensive Care Unit: A Quality Improvement Approach on X-Ray Practices

• Ryu JH
• Shin SH
• Choi YH
• Kim EK
• Kim HS

• KMID: 2561517
• DOI: http://doi.org/10.5385/nm.2024.31.3.56

Abstract

Purpose
Radiographic examinations are frequently performed for diagnostic and therapeutic purposes in neonatal intensive care units (NICUs). However, concerns are emerging regarding the safety of radiation exposure, especially in vulnerable preterm infants in periods of rapid cellular division. This quality improvement (QI) project aimed to reduce radiation hazards in level-IV NICU.
Methods
We established an "X-ray prescription protocol" and educated the physicians to ensure that only essential radiographs were obtained. Additionally, we discouraged full-body infantograms and emphasized the prescription of targeted radiographs, such as chest or abdominal radiographs. Furthermore, to reduce the dose-area product (DAP, Gy·cm²) values, which act as a surrogate for radiation exposure, we provided training to radiologic technologists on meticulous collimation for each radiography session. We aimed to achieve a 30% reduction in the average monthly cumulative DAP per patient, which was calculated by dividing the total monthly DAP from radiographs in the NICU by the monthly average of patient admissions. Retrospective baseline data were collected 8 months pre-intervention and prospectively for 4 months post-interventions.
Results
The average monthly X-ray count per patient was 28.3 in the pre-intervention period (October 2022 to May 2023), which decreased to 25.4 in the post-intervention period (June 2023 to September 2023), reflecting a 10.2% reduction (p=0.109). The average monthly infantogram count per patient showed an 18.0% reduction (25.9% to 21.2%, p=0.016), and the proportion of infantograms in the total X-ray counts decreased from 91.5% to 83.3% (p=0.017). The DAP value per X-ray decreased by 42.6%, from an average of 0.25 to 0.14 (p=0.011). The primary outcome, the average monthly cumulative DAP value per patient, showed a substantial reduction of 48.6%, dropping from 7.00 to 3.60 (p=0.004). The baseline characteristics and short-term morbidities of the patients did not differ significantly between the pre- and post-intervention period.
Conclusion
Our QI approach, which included discouraging excessive prescriptions of infantograms and promoting optimal collimation, significantly reduced the average monthly radiation exposure in the NICU, benefiting both patients and healthcare workers.

Keyword

Radiation; Infantogram; X-rays; Dose area product; Prematurity

Figure

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  Figure 1. Key driver diagram summarizing specific interventions. Abbreviation: NICU, neonatal intensive care unit.

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  Figure 2. (A) U-chart of monthly number of infantogram per patient. (B) U-chart of monthly number of chest or abdominal X-ray per patient. Abbreviations: UCL, upper control limit; CL, center limit; LCL, lower control limit.

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  Figure 3. Run chart of average dose-area product (DAP) value. Abbreviation: CL, center limit.

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  Figure 4. U-chart of monthly cumulative dose-area product (DAP) value per patient. Abbreviations: UCL, upper control limit; CL, center limit; LCL, lower control limit.

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