Assessment
of Compliance to European Commission on Quality Criteria for Diagnostic
Paediatric
Radiography
in Southern Nigeria
Etieno
Augustine Essien, Augustine Dick Essien, Lapah Pièrre Takem, Nneoyi Egbe
Essien Augustine
Etieno, Nneoyi Egbe, Department
of Radiography and Radiological science, Faculty of Allied Medical Sciences,
College of Medical Sciences, University of Calabar, Cross River State, Nigeria
Augustine Dick
Essien, Lapah Pièrre Takem, Department
of Pharmacology, Faculty of Basic Medical Sciences, College of Medical
Sciences, University of Calabar, Cross River State, Nigeria
Correspondence to: Etieno Augustine Essien, Department of Radiography and Radiological
science, Faculty of Allied Medical Sciences, College of Medical Science,
University of Calabar, Cross River State, Nigeria.
Email: etiadorable@gmail.com
Telephone: +2347067040317
Received: March 20, 2015
Revised: June 19, 2015
Accepted: June 25, 2015
Published online: June 29, 2015
ABSTRACT
Background: Quality and
safety have become bedrocks for efficient and successful medical intervention
throughout the whole world.
Objective: To assess for
quality screening practice in paediatric radiography; compliance with European
Commission guide lines for diagnostic paediatric radiography in Southern
Nigeria.
Materials and Methods: University Teaching Hospitals and private health
centres in Southern Nigeria were screened through questionnaires and on-site
observation of paediatric radiography practices. The questionnaires contained
the recommended parameters of EC in respect of skull, chest and abdominal
radiography imaging.
Results: They revealed
that radiography device (RD) usage had good scores in all medical institutions.
Nominal focal spot value (NFSV), tube filtration (TF), Film-focus distance
(FFD) had good scores only in public hospitals. Automatic exposure control
(AEC) had good scores only in private health centres. Quality assurance was
good for public hospitals. Most of X-ray machines were manufactured 31 years
ago and installed about 37 years ago.
Conclusion: University
Teaching Hospitals had fair compliance to EC recommendations than private
health centres. The poor compliance was probably due to lack of proficient
radiography technologists, lack of adequate information necessary in carrying
out paediatric radiography, use of obsolete equipment or lack of incentives.
© 2015 ACT. All
rights reserved.
Key words: Paediatric; Radiography; European Commission; Hospital
Essien EA, Essien
AD, Takem LP, Egbe N. Assessment of Compliance to European Commission on Quality Criteria for
Diagnostic Paediatric Radiography in Southern Nigeria. International
Journal of Radiology 2015; 2(1): 38-41 Available from: URL:
http://www.ghrnet.org/index.php/ijr/article/view/1268
Introduction
Paediatric radiography is a sub-specialty of
radiology involving imaging of fetuses, infants and children, adolescents and
young adults. Paediatric radiology is the use of any imaging modality to
prevent, detect, diagnose and treat diseases in children[1].
Paediatric radiography procedure is different from that of the adult although
some diseases seen in paediatric are same as that of adult[2].
Children undergoing these examinations are expected to be given special
attention, both because of the diseases specific to childhood and the
additional risks to them. In addition, children need special care and comfort
as well as care that has to be provided by specially trained health
professionals[1].
Some tissues in children are more susceptible to damaging effects of
ionizing radiation than those in adults. Organs and tissues are closer together
in small children making them harder to exclude from the primary beam and to
protect them from scattering. Children also have thinner layers of abdominal
visceral fat; thus, the natural contrast usually available in adults is much
reduced[3-5]. Children have a two to four times higher risk of late
manifestation of radiation induced neoplasms[6].
Radiographers working with children need skill and experience in order
to gain their patient’s confidence and cooperation. Commitment to paediatric
examination is very essential as well as understanding of child’s needs,
development, psychology and ranges of pathologies that is required of the
examination.
Commission for European communities (CEC) has given minimum parameters
so that at all times radiation dose to the patient is reduced without reduction
in image quality. For this to be achieved, a high quality service must be
provided through the safe and accurate performance of a deliberate plan of
action. This must be based on an ethical approach and an understanding of the
increased sensitivity of a child to ionizing radiation[7]. Achieving
diagnostic quality radiographs whilst minimizing patient dose is the goal of
any imaging department and this is more important in paediatric because of the
development that takes place in children.
Saddled with these challenges, the present research work was carried out
to investigate the state of affairs in some public and private medical
institutions in South-Eastern region of Nigeeria.
Materials
and Methods
Subjects
The target population for this research included chief radiographers
and their assistants, practicing radiographers and workers of the department of
paediatric radiography working in University Teaching Hospitals and private
health centers in Southern Nigeria.
Methodology
Multi centre sampling method was adopted as descript by Linda[8].
Questionnaires were shared between University Teaching Hospitals and private
health centres containing minimum parameters as recommended by European
Commission[9]. The department of paediatric radiography was given a
form to fill concerning departmental practice in paediatric examinations for
chest, abdomen and skull radiography. All the questions asked were on the
following: Radiography device (RD), Total filtration/ Tube filtrate/added
filtration (TF), Nominal focal spot value (NFSV), Anti-scatter grid (ASG),
Screen-film system (SFS), Film-focus distance (FFD), Radiographic voltage (RV),
Automatic Exposure Control (AEC), Exposure time in Milli ampere per second
(MAs), Protective shielding (PS), quality assurance (QA), International
European commission (IEC), European Commission (EC). A scoring system of ‘1’
for compliance and ‘0’ for non-compliance to EC criteria was used. This
research work was carried out under strict UCL Research Ethics Committee
guidelines[10].
Statistical
analysis
Data were analyzed using Pickering and Weatherall method[11].
Results
Compliance of University Teaching Hospitals and
private health centres to EC recommendations for good practice in paediatric
chest radiography is shown in table 1. All the medical institutions possess RD
and scored good while TF and FFD measured in accordance with EC. All institutions scored low in RV, PS,
MAs except CXD that scored good in PS while UPTH scored good in MAs and UUTH in
RV. Total score for University Teaching Hospitals was 15 while that of private
health centers was 14.
Compliance of University Teaching Hospitals and private health centres
to EC recommendations for good practice in paediatric abdomen radiography is
shown in table 2. Again all institutions showed good scores for RD while only
UUTH showed low scores in TF and SFS. Only UPTH scored good in PS while UUTH
scored good in RV. Total score for University Teaching Hospitals was 20 while
for private health centers was 12.
Compliance of University Teaching Hospitals and private health centres
to EC recommendations for good practice in paediatric skull radiography is
shown in table 3. All institutions scored good in using PS. Only CXD scored low
in TF and ASG. Total score for University Teaching Hospitals was 24 while for
private health centers was 20.
Comparative percent compliance of University Teaching Hospitals and
private health centers to EC recommendations is shown in figure 1. In paediatric
abdomen imaging, there is no great change between University Teaching Hospital
and private health centres. In paediatric chest and skull radiography, there is
significant change between University Teaching Hospitals and private health
centres with the former being high in chest radiography while latter being high
in skull radiography as compared to EC standards.
Discussion
The findings that compliance of University Teaching
Hospitals and private health centres in paediatric radiography were largely on the
margin of EC recommendation may have implications for children’s health and
development.
Methodological aspect
In the course of administering the questionnaires,
some hospitals were on industrial strike action. However, they were still
reached after the strike and it is believed that respondent had no bias mind in
filling the questionnaires though it was time consuming for the researchers.
There was also lack of adequate funds to explore all the Teaching
Hospitals in the country and to have an in-depth view of paediatric radiology
imaging to ascertain the image quality and dosing. Nevertheless, it is believed
that the sample size used is reflective of the real state of affairs in the
country.
Compliance level
It was observed that X-ray machines were mostly
manufactured 31 years ago and installed about 27 years ago even though but was
hard to ascertain the functionality of the device since some of the
institutions had no patients at the time of visit. However, a lot of time was
spent on waiting for patients to avail for radiology imaging exercise. Most of
University Teaching Hospitals had children waiting for imaging tests which
could be linked to relatively cheap charges as compared to private health
centres. Quality assurance was good for public hospitals as compared to private
health centres probably due to funding from indigenous politicians who seek for
votes.
It was generally revealed that anti-scatter grid use was not based on
patient thickness and field of view (FOV) but rather on age. Meanwhile,
removing anti-scatter grid for children/small patients reduces dose without a
substantial increase in scatter-to-primary ratio when FOV is restricted
appropriately[12].
The quality and radiation dose of different tube voltage sets for chest
digital radiography was not complied with by both University Teaching Hospital
and private health centres. It has been proven that higher kVp may help
optimize the trade-off between radiation dose and image quality and it may be
acceptable for use in a pediatric age group[13].
In private health centres, this research work revealed that normal spot
focus usage was till problematic as depicted from scanned images. The shape and
size of a focal spot influence the resolution of a radiographic image. An
increase in focal spot size, which may accompany deterioration of the X-ray
tube, reduces the ability to define small structures[14].
The quality control programmes in private health centres was low
probably because of the quality administrative procedure. There were less
observed management actions intended to ensure that monitoring techniques are
properly performed and necessary corrective measures to be taken in response of
monitoring results. There were also lack of quality control techniques which
are techniques used in the monitoring or testing and maintenance of the
components of an X-ray system.
Conclusion
Despite the time consuming nature of this research,
the objective of it was satisfactorily achieved even though finance proved to
be unfriendly. University Teaching Hospitals, which are government funded,
showed greater adherence to EC recommendations in paediatric radiography than
private health centers. However, the compliance is still to be improved as it
is seen with their on-and-off strike battles with the Federal Government.
Radiologic technologist should be provided with opportunities to sharpen their
proficiency through workshops, seminars and conferences. There should be
installed monitoring teams in every X-ray Department to enforce quality control
programmes.
Appendix
1.European commission guidelines for standard radiographical practice[15].
2. Criteria for radiation dose to patient Entrance surface dose for a
standard-sized patient: 0.3 mGy.
3. Example of good radiographic technique.
3.1. Radiographic device: vertical stand with stationary or moving grid.
3.2. Nominal focal spot value: <1.3.
3.3. Total filtration: >3.0 mm AI equivalent.
3.4. Anti-scatter grid: r = 10; 40/cm.
3.5. Screen film system: nominal speed class 400.
3.6. FFD: 180 (140-200) cm.
3.7. Radiographic voltage: 125 kV.
3.8. Automatic exposure control: chamber selected - right lateral.
3.9. Exposure time: < 20 ms.
3.10. Protective shielding: standard protection.
Authors
contributions
Author EAE designed the work and acquired data;
author ADE drafted the article; author NE and LPT analyzed the study and
managed literature searches. All authors read and approved the final
manuscript.
CONFLICT OF
INTERESTS
There are no
conflicts of interest with regard to the present study.
REFERENCES
1. Safety Reports Series No. 71.
Accessed 20 January 2015. Available from URL:
http://www-pub.iaea.org/MTCD/Publications/PDF/Pub1543_web.pdf
2 Whitley AS, Sloane C, Hoadley
G, Moore DA and Alsop CW. Clark’s positioning in Radiography. Oxford University
Press, London 2005, p.112
3 Image Gently, The Alliance
for Radiation Safety in Paediatric Imaging. Available from URL:
http://www.pedrad.org/associations/5364/ig/
4 Ron E et al. Thyroid cancer
after exposure to external radiation: a pooled analysis of seven studies.
Radiat. Res 1995; 14: 259-277.
5 European Commission, Council
Directive 1997/43/Euratom on Health Protection of Individuals Against Ionizing
Radiation in Relation to Medical
Exposure. Off. J. Eur. Commun. L. 180, Luxembourg 1997; 22–27.
6 UNSCEAR Report, 2000.
Available from URL: www.unscear.org/unscear/en/publications/2000_2.html
7 Vock P. CT dose reduction in
children. Eur Radiol 2005; 15: 2330–2340.
8 Linda TK. Methods in Case Study
Analysis. The Center for Studying Health System Change. Technical Publication
No. June 1997. Accessed 18 January 2014. Available from URL:
http://www.hschange.com/CONTENT/158/158.pdf
9 Kohn MM, Moores BM, Schibilla H et
al. European guidelines on quality criteria for diagnostic radiographic images
in paediatrics. Accessed 10 February 2015. Available from URL:
ftp://ftp.cordis.europa.eu/pub/fp5-euratom/docs/eur16261.pdf
10 UCL Research Ethics Committee.
Accessed 18 June 2015. Available from URL:
https://ethics.grad.ucl.ac.uk/forms/guidelines.pdf
11 Pickering RM, Weatherall M. The
analysis of continuous outcomes in multi-centre trials with small centre sizes.
Statist. Med. 2007;26(30):5445–5456
12 Shannon
F and Kyle JA. Guidelines for anti-scatter grid use in pediatric digital
radiography. Pediatric Radiology 2014; 44(3): 313-321
13 Hui G, Wen-Ya L, Xiao-Ye H,
Xiao-Shan Z, Qun-Li Z, and Bai-Yan L. Optimizing Imaging Quality and Radiation
Dose by the Age-Dependent Setting of Tube Voltage in Pediatric Chest Digital
Radiography. Korean J Radiol 2013:;14(1): 126–131.
14 Focal spot. Accessed 25 May 2015.
Available from URL:
http://www.medical-dictionary.thefreedictionary.com/focal+spot
15 Protocols for Standard Radiological
Practice – Good Practice Guidelines. Accessed 18 June 2015. Available from URL:
http://www.hse.ie/eng/about/Who/qualityandpatientsafety/safepatientcare/medexpradiatonunit/Protocols%20for%20Standard%20Radiological%20Practice.pdf
Peer reviewers: Janney
Sun, Editor-In-Chief, International Journal of Radiology,
Unit A1, 7/F, Cheuk Nang Plaza, 250 Hennessy Road, Wanchai, Hong Kong.
Refbacks
- There are currently no refbacks.
This work is licensed under a Creative Commons Attribution 3.0 License.