ESR statement on radiation protection: globalisation, personalised medicine and safety (the GPS approach)

The ESR is convinced that the different components of radiation protection are often interrelated and cannot be considered in isolation and independently, something that tends to be overlooked by many. Impacting on steps in preparing a referral for imaging by physician, appropriate decision-making for a particular study, scheduling, standardised imaging protocol, optimisation in conduct of examination and procedure by radiographer, involvement of medical physicist for oversight in imaging with minimum dose and desired image quality, recording of doses, QC and, finally, reporting of the study provide a holistic and overall approach (referred to as “global” here, covering the various steps in the chain and involving all stakeholders). In addition, coverage of a larger population through tele-radiology, using methodology of campaign, incentive policies, involvement of medical board, regulators and industry through COCIR for technological developments, education and training, communication as well as clinical audit, provides a complete coverage. There has been growing realisation that regulations alone are insufficient. The purpose is to have appropriate tools and support of medical community and stakeholders.

The ESR’s vision: personalised medicine with patient-centricity in clinical settings. Personalised medicine is a development in the whole field of medicine. Unlike optimisation, where scores of successful examples of patient-centricity can be found, there is a paucity of streamlined actions on patient-centric appropriateness (justification at levels 2 and 3). The ESR plans to have a phased program supported by an electronic “Clinical Decision Support” (CDS) system, with initial emphasis on CT, paediatrics, women and interventional radiology. In primary care for example (ambulatory care) mainly general practitioners (GPs) are involved with a very low-scale IT environment and mostly dealing with non-vital diseases. However, in this setting there can be overuse and misuse of imaging. For the ESR, this is also an issue of awareness, besides making available guidelines. There are typically five to ten known situations with the highest number of CT scans. For secondary care, appropriateness in hospitals is totally different from that in primary care settings. A focus on emergency departments would be efficient, selecting also here typical scenarios with overuse of imaging (pulmonary embolism, head trauma, abdominal pain, etc.). For tertiary care (specialised surgery, interventional radiology) needs are again to be seen in a totally different context. It relates to specialties with a therapeutic approach where risk/benefit has a sense and with true patient contact. In this setting, it will be important to have a holistic approach, and optimisation (including staff protection) becomes most important. Personalised medicine also involves considerations of difference in risks for children, aged persons, persons with chronic and oncological disease, and those with genetic variations increasing radiosensitivity.

Radiation protection is an important pillar of the safety culture in radiology. Besides optimisation, justification, clinical audits and education, diagnostic reference levels (DRLs) are valuable tools. The ESR wishes to promote establishment of dose repositories to support dose management and clinical audit to document improvement. Technology holds the key to developments in patient and staff radiation safety [7], and thus developing and utilising dose management tools has the greatest potential. Sub-mSv dose of CT of any body part (head, chest, abdomen, pelvic), dose alerts to avoid overexposures, alert when higher than reference levels are going to be given, communication of dose indices across European countries, dose tracking of an individual patient [8], web-based dose information access to physicians—including on mobile devices, individualised patient-protection-based dose repository, dose maps for the individual patient, eye lens dose estimations and dose maps for patient dose shall provide the needed actions to achieve a high level of safety.

It can be anticipated that the CDS system will allow the protection of patients in Europe through appropriateness, optimisation actions through technological improvements, dose recording and dose management using DRLs, awareness through website and newsletters and training with certification will all converge to patient safety and will provide a holistic (global) approach. Although the focus is on patient safety, staff safety issues will find a place wherever pertinent.