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  • Imaging Safety Movement Expands Across the Globe

    Europe, Africa, Japan, Latin America and Canada support safe imaging. By Nick Klenske

    May 1, 2018

    In 2010, leading North American radiology organizations including RSNA introduced Image Wisely®, a program dedicated to raising awareness about optimizing the radiation used in medically necessary imaging studies and eliminating unnecessary procedures in adult patients.

    Image Wisely was launched by RSNA, the American College of Radiology (ACR), the American Association of Physicists in Medicine (AAPM) and the American Society of Radiological Technologists (ASRT) with the goal of championing the safe and effective use of medical imaging for adult patients and disseminating these concepts to the radiology profession and other medical professionals. RSNA is also a member of the Image Gently Alliance, a coalition of healthcare organizations dedicated to providing safe, high quality pediatric imaging worldwide. The Image Gently® campaign was launched in 2007.


    In the years that followed, other medical imaging safety initiatives have formed across the globe, including in Europe, Africa, Japan, Latin America and Canada.

    For example, EuroSafe Imaging, launched in 2014, is the European Society of Radiology’s flagship initiative for promoting quality and safety in medical imaging. EuroSafe Imaging was designed to support the International Atomic Energy Agency Call for Action issued in Bonn, Germany, in 2012.

    While there is general agreement in the radiology community that certain imaging procedures carry risk, there is also consensus that with appropriate utilization, low-dose protocols and implementation of programs that evaluate patient doses the potential benefits far outweigh that risk.

    “What is unique about Image Wisely is that it is not about promoting the use of lower doses, but about finding the optimal amount of radiation needed to produce high-quality images,” said Richard L. Morin, PhD, Emeritus Department of Radiology and Brooks Hollern Professor Emeritus at the Mayo Clinic and co-chair of the Image Wisely Executive Committee and ACR representative. Elliot K. Fishman, MD, serves as co-chairman of the Image Wisely Executive Committee and as the RSNA representative.

    The launch of ImageWisely.org offered individuals and practices the opportunity to pledge to optimize the use of radiation in adult patients undergoing imaging. While the pledge began as a one-time commitment, participants are now asked to make the pledge annually. (See Web Extras.)

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    Joining for a Common Goal

    As Image Wisely and EuroSafe Imaging began to grow and gain traction, radiology organizations around the world were inspired to develop their own safe imaging programs.

    “Image Wisely is widely respected among the international community, with other organizations often turning to us for advice,” Dr. Morin said.

    However, Dr. Morin is quick to note that this does not mean all organizations are identical. Instead, each organization reflects the region’s unique imaging culture and needs.

    Launched in 2015, Canada Safe Imaging (CSI) brings together all organizations and participants involved in medical radiation safety and invites them to join an initiative designed to promote radiation safety in all institutions.

    “As healthcare is a provincial responsibility, we want to achieve coordination and standardization across the country, along with creating tools to help regulators and accreditors in their work,” said David A. Koff, MD, FRCPC, professor and chair, Department of Radiology, McMaster University, Ontario, Canada.

    Rather than reinventing the wheel, Dr. Koff said CSI is leveraging the wealth of information collected by other campaign websites, including Image Wisely.

    “The definition of what it means to ‘image wisely’ is no different in Canada than in the United States or other developed countries,” he said. “But limited access to equipment and long wait times make excess utilization less likely in Canada than in the U.S.”

    LatinSafe, which was also launched in 2015, is an educational initiative primarily designed to produce material for a better understanding of imaging techniques that use ionizing radiation for diagnosis and treatment. “LatinSafe was strongly influenced by the Image Wisely initiative, especially our website and the taking of a pledge,” said Hilton Muniz Leão Filho, MD, director of LatinSafe and an abdominal radiologist at Hospital das Clínicas da Faculdade de Medicina, São Paulo, Brazil.

    In Africa, AFROSAFERAD — founded in 2015 — is focused on applying the 3As: awareness, appropriateness and audit, said Michael G. Kawooya, MBChB, MMed (Rad), PhD, at the Ernest Cook Ultrasound Research and Education Institute at Mengo Hospital, Kampala, Uganda.

    “A major achievement under this action has been the launch of AFROSAFERAD, which is Africa’s radiation protection campaign platform,” Dr. Kawooya said. “This platform is instrumental in facilitating the application of the 3As, especially awareness.”

    Japan Safe Radiology, founded in 2016, is working to improve the safety and efficiency of medical imaging by implementing structural reforms. Although the organization is primarily focused on setting standards for dose usage, members recently began adding radiation awareness activities to its agenda as well.

    “Image Wisely inspired us to start including activities that raise awareness about opportunities to eliminate unnecessary imaging examinations and to lower the amount of radiation used to what is needed to acquire quality medical images,” said Kanako Kunishmima Kumamaru, MD, PhD, associate professor, Department of Radiology at Juntendo University School of Medicine, Japan.

    Established safety campaigns also served as models for ArabSafe launched in 2017. ArabSafe is dedicated to establishing a culture of radiation safety among Arabic speaking countries and ensuring the appropriate use of radiation in medicine.

    “We saw the Image Wisely campaign as something that we could adapt to the needs of Arab countries,” said Boudjema Mansouri, MD, professor of medical imaging and radiology at the University Hospital of Bab El Oued, Algiers. “Being able to collaborate with our counterparts in the U.S. and learn from their resources and expertise has allowed us to implement the structural reforms needed to improve the safety and efficiency of medical imaging.”

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    Healthcare System Drives Focus in Europe

    While EuroSafe Imaging is in line with other imaging safety organizations dedicated to supporting and strengthening medical radiation protection, EuroSafe Imaging follows a holistic, inclusive and multi-stakeholder approach to realizing that goal.

    EuroSafe Imaging was launched under the general umbrella of the European regulations for medical applications. Updated in 2018, the regulations address the full scope of medical radiation protection, including occupational issues.

    “Our experience is that having a comprehensive regulatory body in a given country makes it easier to take a professional approach to implementing radiation protection policies into daily practice,” said Guy Frija, MD, chair of EuroSafe Imaging and co-chair of the International Society of Radiology Quality and Safety Alliance. “This in part helps explain why EuroSafe Imaging tends to take a more holistic approach to radiation protection.”

    Dr. Morin notes that this difference is largely tied to healthcare in Europe, which mainly operates under a single payer system, negating the need for a campaign pledge model.

    “In places with single payer systems, such as Europe, you do not need pledges as you can advocate for and regulate the maximum level of radiation allowed for a particular type of study,” Dr. Morin said. “Such a system simply doesn’t work in the U.S., which is why the focus of Image Wisely is on raising awareness and using the pledge to self-regulate.”

    Raising Awareness Across the Globe

    Although each of these organizations is taking a unique approach, all are making impressive gains in their common commitment to strengthening radiation protection across the world. According to Dr. Morin, the Image Wisely campaign, along with its international counterparts, are succeeding in their goal to optimize radiation dose.

    “There is no question that since the launch of these initiatives, the dose index has gone down,” Dr. Morin said. “Image Wisely has played a substantial role in accomplishing this by ra ising awareness – both here at home and abroad.”

    And that is the role Image Wisely will continue to play, Dr. Fishman said.

    “The future of radiation safety initiatives like Image Wisely remains relevant to improve patient care,” Dr. Fishman said. “We will continue to engage our professional colleagues to optimize the use of radiation in medically necessary imaging. And will continue to update and expand our educational materials to spread awareness on this issue.”

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    The ISR Quality and Safety Alliance (ISRQSA), co-chaired by the EuroSafe Imaging and Image Gently chairs and including representatives of the regional safe imaging campaigns (above), met at the International Atomic Energy Agency conference, held in Vienna in December 2017. Image courtesy of ISRQSA.

    Radiation Safety Cases Offered on ImageWisely.org.

    In 2013, Image Wisely® launched its first Image Wisely Radiation Safety Case — a series of free, online and mobile-compatible educational offerings that allow radiologists, imaging technologists and medical physicists to assess their own understanding of important radiation safety concepts such as radiation dose monitoring and optimization.

    To access the full list of cases, including the newest case, “Child-sizing CT Dose: Optimizing Patient Care Through Quality Improvement– Pediatric and Adult Imaging (developed by Image Gently®),” go to ImageWisely.org.

    CT Machine

    Web Extras