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Reduction In Patient Radiation Exposure During Ureteroscopy Through the Use of a Pre-Fluoroscopy Checklist

Saturday, October 20, 2012: 1:45 PM
Grand Ballroom A/B (Hilton Riverside)
Paul J. Kokorowski, MD, MPH1, Jeanne Chow2, Keith Strauss, MSc2, Melanie C. Pennison, M.P.H.1, Bartley Cilento, MD1 and Caleb P. Nelson, M.D., M.P.H.1, (1)Department of Urology, Children's Hospital Boston, Boston, MA, (2)Department of Radiology, Children's Hospital Boston, Boston, MA

Purpose: Medical radiation exposure is a significant concern, particularly in the pediatric population. Previously, we prospectively measured radiation exposure during retrograde ureteroscopy (URS) for urolithiasis in children, and documented substantial exposure to these patients. Based on these findings, we identified potential sources of excess exposure and developed an intervention centered around a checklist. We sought to evaluate whether implementation of this systematic intervention would reduce radiation exposure during pediatric URS.

Methods: Using the factors identified in our prospective radiation measurements, we developed pre-fluoroscopy quality checklist to be used in the operating room during pediatric URS for urolithiasis. This checklist was instituted as part of a larger quality improvement initiative. The checklist specifically addresses issues regarding positioning of the patient and c-arm, settings on the fluoroscope, and communication between surgeon and technologist. Pre-operative patient characteristics, operative factors, fluoroscopy settings and radiation exposure were recorded before and after implementation of the checklist. Primary radiation exposure outcomes were entrance skin dose (ESD, in mGy) and midline dose (MLD, in mGy), calculated based on output from the fluoroscopy unit and positioning and size of the patient.

Results: Results of 37 procedures performed during the pre-intervention phase were compared with those of 23 procedures during the intervention phase. Pre- and post-checklist groups were similar with regard to patient age (mean 14.8±4.0 vs 15.3±5.8 yrs), total surgical time (mean 72.8±45.4 vs 71.5±36.4 min), or patient thickness (mean 18.6±4.3 vs 17.7±3.5 cm).  Mean ESD was reduced by 87% (mean 46.4±48.0 vs 6.4±8.5 mGy, p<0.01) and mean MLD by 86% (mean 6.2±5.0 vs 0.9±0.8 mGy, p<0.01). Significant improvements were noted among the major determinants of radiation dose including the total fluoroscopy time reduced 66% (mean 2.7±1.8 vs 0.9±0.9, p<0.01), dose rate setting appropriately reduced setting in 91% vs 51% (p<0.01), and excess skin to intensifier distance reduced by 74% (mean 12.3±6.7 vs 3.2±5.1, p<0.01).

Conclusion: Implementation of a pre-fluoroscopy checklist, as part of an intervention aimed at reduction in radiation exposure, resulted in statistically and clinically significant reductions in radiation exposure to patients during pediatric ureteroscopy. This simple tool, and the larger awareness of radiation issues it promotes in the operating room, can have a dramatic impact in exposure to children undergoing endourologic procedures.