ASSESSMENT OF PAEDIATRIC X-RAY EXAMINATION PRACTICES IN TWO TERTIARY HEALTH INSTITUTIONS (CASE STUDY OF ENUGU METROPOLIS)

TABLE OF CONTENTS

Title Page…………………………………………………………………………………………………….i

Dedication……………………………………………………………………………………………………ii

Approval Page……………………………………………………………………………………………..iii

Certification…………………………………………………………………………………………………iv

Acknowledgement………………………………………………………………………………………..v

Table of Contents…………………………………………………………………………………………vi

List of tables………………………………………………………………………………………………..vii

List of figures………………………………………………………………………………………………viii

Abstract……………………………………………………………………………………………………….ix

CHAPTER ONE: INTRODUCTION

1.1     Background of study…………………………………………………………………………….1

1.2     Statement of the problems…………………………………………………………………….4

1.3     Purpose of the study……………………………………………………………………………..4

1.4     Significance of the study……………………………………………………………………….5

1.5     Statement of hypotheses………………………………………………………………………..6

1.6     Scope of the study…………………………………………………………………………………6

1.7     Literature review…………………………………………………………………………………..7

CHAPTER TWO: THEORITICAL BACKGROUND

2.0     Paediatric radiography………………………………………………………………………….15

2.1     Child development and psychological considerations………………………………16

2.2     Environment………………………………………………………………………………………..17

2.3     Challenges…………………………………………………………………………………………..18

2.4     Paediatric radiation protection issues……………………………………………………..18

2.5     Equipments………………………………………………………………………………………….19

2.6     Justification of radiological exposures……………………………………………………20

2.7     Optimization for paediatric radiation protection………………………………………21

2.8     X-Radiation…………………………………………………………………………………………21

2.9     General recommendations for paediatric radiology………………………………….26

CHAPTER THREE: RESEARCH METHODOLOGY

• Research design…………………………………………………………………………………..30

3.2     Target population…………………………………………………………………………………30

3.3     Sources of data collection……………………………………………………………………..30

3.4     Method of data collection……………………………………………………………………..30

3.5     Method of data analysis………………………………………………………………………..35

CHAPTER FOUR: DATA ANALYSIS AND PRESENTATION

4.1     Frequency distributions of common paediatric x-ray examinations…………..36

4.2     Radiographic techniques and image quality…………………………………………….42

4.3     Image quality audit……………………………………………………………………………….48

4.4     Causes of film reject…………………………………………………………………………….49

CHAPTER FIVE: DISCUSSION, CONCLUSION AND RECOMMENDATIONS

5.1     Discussion…………………………………………………………………………………………..50

5.2     Summary of findings…………………………………………………………………………….56

5.3     Recommendations………………………………………………………………………………..58

5.4     Limitations of the Study……………………………………………………………………….58

5.5     Areas of Further Research…………………………………………………………………….58

References

Appendix

LIST OF TABLES

Table 1:Radiological examination/projections included in the study

Table 2: Image criteria for anteroposterior/posteroanterior chest examinations from the, “European guidelines on quality criteria for diagnostic radiographic images”.

Table3:A graded scoring system developed to highlight the differences between the two departments.

Table 4a:Monthly distributions of common paediatric x-ray examinations at UNTH

Table 4b: Monthly distribution of common paediatric x-ray examinations at NOHE

Table 5a:Age/gender distribution for common paediatric x-ray examinations at UNTH.

Table 5b: Age/gender distribution for common paediatric x-ray examinations at NOHE.

Table 6:Percentage of films displaying poor radiographic techniques with regard to radiation protection and image quality

Table 7:Percentage of films displaying excellent radiographic techniques with regard to radiation protection and clinical information displayed.

Table 8: Comparison between examination type and poor radiographic techniques

Table 9:Comparison between examination type/projection and image quality

Table 10: Comparison of radiographic techniques and image qualitybetween UNTH and NOHE

Table 11:Image quality audit practice at UNTH and NOHE

Table 12:Frequencies of common causes of film reject in paediatric examination practices in UNTH.

LIST OF FIGURES

Figure I:Frequency chart for Paediatric x-ray examination UNTH

Figure II:Frequency chart for routine paediatric x-ray examinations in NOHE.   

Figure III:Percentage of films which satisfies the European Image Criteria.

ABSTRACT

Justification and optimization are the key principles in the protection of patients exposed to ionization radiation from diagnostic purposes. This is more important in the imaging of children because they are more susceptible to the effect of ionizing radiation and they have longer life expectancy compared to adults. As a result of this, there is also recent requirement for diagnostic radiology department to demonstrate compliance with these principles. A study was carried out to assess and compare the paediatric x-ray examination practices in two tertiary institutions in Enugu metropolis, UNTH and NOHE, with the aim of determining the frequency of paediatric x-ray examinations, quality of radiographic techniques and image quality, practice of image quality criteria and feedback to staff, and causes of film reject, The departmental registers were used to determine the frequency of common paediatric x-ray examinations. Retrospectively, 40 radiographs were collected from the medical records of the two radiologicaldepartments studied, to determine the quality of radiographic techniques and image quality, while 34 rejected radiographs were collected over a period of 3 weeks at UNTH to determine the causes of film rejects in this department. Some radiographers were interviewed to ascertain the practice of image quality audit. All the radiographs collected were assessed by a radiographer from each department. The data was analyzed and the result showed that the paediatric x-ray examination request patterns are not the same in the two departments studied. While UNTH has high number of chest request which accounts 62.1%, with higher percentage of males (57.7%) under the age groups of 0-5 years, NOHE has extremities as the most common requested x-ray examination which accounts 71.2%, with higher percentage of females (50.5%) but higher percentage of males are under the age group of 0-5 years (41.4%). In both departments, more than half of films of the film assessed satisfied most of the European image criteria; 69.3% at UNTH displayed excellent radiographic techniques, and 65.7% at NOHE. The image quality audit and feedback to staff is not fully practiced. Also, the common cause of film reject at UNTH is “underexposure” which accounts 52.94% of the rejected radiographs. The result of the hypotheses stated showed that examination type/projection requested affects poor radiographic techniques and image quality in each department and there is a significant difference in some radiographic techniques between UNTH and NOHE. With all these findings, there is need for self-audit and re-evaluation of procedures where necessary in both departments studied.

CHAPTER ONE

INTRODUCTION

• BACKGROUND OF STUDY

Paediatric radiography is a subspecialty of radiology involving the imaging of fetuses, children, adolescents and young adults. In radiography, paediatricsconstitutes patients within the age range of 0-15years. For diagnostic purposes they can be divided into six main groups as follow: (a) Birth-6months, (b) Infancy (6months-3years), (c) Early childhood (3-6years), (d) Middle childhood (6-12years), and adolescent (12-15years).⁽¹⁾  Each of these groups has a peculiar need towards obtaining diagnostic quality images at the least attainable risks. Paediatric radiography involves the use of X-rays in the diagnostic examination of a child for clinical conditions related to the different parts of the body.It has been identified as one of the most common diagnostic procedures in paediatrics, both the sick and the healthy ⁽²⁾.

To successfully diagnose a paediatric condition, high quality images are needed. Children can be uncooperative and obstructive when undergoing radiography and often challenge the very technique and ability of the imaging staff within whose custody they have been temporarily placed. Therefore,paediatric radiography comes with many challenges.

Medicine has used ionizing radiation for decades to help diagnose or treat children (and adults).  There isno doubt that imaging has saved lives.  Medical imaging use has also grown exponentially in the past few years, ⁽³⁾ particularly in paediatric radiography.  Thus, thereis frequent demand of x- ray examinations for diagnosis of a number of paediatric pathologies.

The United Nations Scientific Committee on the Effects of Atomic Radiation (UNSCEAR, 2008), estimated that worldwide, there were 3.6 billion imaging studies per  year (survey covering period of 1997- 2007) using ionizing radiation comparing the previous report of 2.4billion per year (survey covering period of 1991 – 1996) – an increase of approximately 50%⁽³⁾. It was also reported by Arroe that the frequency of examinations changes, depending on the neonatal birth weight (BW), age and disease of the child ⁽⁴⁾. In addition, there is substantial evidence to suggest that children are more susceptible to the effects of ionizing radiation than adults ⁽⁵⁾, which places an added burden on radiographers to attain the best possible result every time.

The United Nations Scientific Committee on the effects of Atomic radiation (UNSCEAR)⁽³⁾ also, emphasized that risks from exposure to ionizing radiation are dependent on the age at which exposure occurs and that exposure during childhood results in a likely two to three (2-3) fold increase in life time risk for certain detrimental effects (including solid cancers) compared with that in adults: children, therefore need more careful evaluation with regard to the frequency of examinations and radiographic technique needs to be even more exacting. European Commission has recognized the need for special treatment of children in the x-ray department, in both the “European guideline on quality criteria for diagnostic radiographic images in paediatrics” ⁽⁵⁾and more recently in the Council Directive 97/43/Euratom ⁽⁶⁾ on the protection of individuals against the dangers of ionizing radiation. The guidelines suggest examples of good radiographic techniques and present useful image quality criteria for a number of common paediatric examinations, with the aim of producing high quality images at lowest possible dose to the patient. The Council Directive 97/43/Eurotom ⁽⁶⁾ recommends that special consideration be given to diagnostic radiographic procedures involving children.

Until now, researches on common routine radiological investigations ofpediatrics were mainly on radiation protection, radiation dose to paediatric patients, estimation of radiation induced cancers to patients, justification and optimization of radiological requests, and others related to the after effects of common routinepaediatric x- ray examinations ^(8-17)_,  but no research to the best of the researcher’s knowledge has been carried out on the assessment of paediatric radiographic practices and request patterns in Nigeria. Therefore the aim of this study is to assess and compare paediatric x–ray examination practices and request pattern in two tertiary health institutions in Enugu metropolis.

1.2     STATEMENT OF PROBLEMS

1. X-ray imaging is being increasingly used for diagnosis of paediatricpathologies². Unfortunately, there is substantial evidence to suggest that children are more susceptible to the effects of ionizing radiation than adults⁽³⁾. Evaluation of the frequency distribution of paediatric examinations therefore becomes very essential.
2. In addition, there is no documented evidence of audit of paediatric radiography practice in our environment to ensure safe and standard practice.
3. The researcher in the course of clinical postings observed that common routine paediatric x-ray examination practices in theradiology departments being studied were not properly documented.

1.3     PURPOSE OF STUDY

The purpose of the study is to assess paediatric X-ray examination practices and request patternin University of Nigeria Teaching Hospital, Ituku-Ozalla (UNTH) and National Orthopedics Hospital Enugu (NOHE), in Enugu metropolis.

The specific objectives are as follows:

1. To determine the frequency of common routine paediatric x-ray examinations and monthly distribution of the frequency of the investigations in the localities studied.
2. To assess the radiographic techniques used, and radiation protection adopted based on radiographic films.
3. To assess the practice of image quality audit and feedback to staff.
4. To assess the causes of rejects in paediatric radiography in these health institutions.
   • SIGNIFICANCE OF STUDY

Findings of this study will portray the quality of the paediatric examination practices in each health institution studied and also provide documented information on the following:

1. The frequency of common routine paediatric x-ray examinationsand their monthly variations, as well as the corresponding projections, in the two tertiary health institutions.
2. Practice of image quality audit and feedback to staff.
3. The causes of film reject in paediatric radiography in these health institutions.
4. The quality of the radiographic techniques used in these departments, as well as the image quality.

 STATEMENT OF HYPOTHESIS

1. There is no significant difference between examination type/projections and poor radiographic techniques.
2. There is no significant difference between examination type/projections and image quality.
3. There is no significant difference in radiographic techniques and image quality between UNTH and NOHE.
   • SCOPE OF STUDY

This research will be carried out in two tertiary health institutions in Enugu metropolis. They include University of Nigeria, Teaching Hospital, Ituku–Ozalla (UNTH) and National Orthopedics Hospital, Enugu (NOHE). The department register and patient request cards will be assessed, for a period of one year, between the months of January 2011 to December, 2011, to determine the frequencies of common routine examinations. This study will cover paediatricpatients within the age range of 0-15years.

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