Summary Report of the Fourth Meeting of the Steering Panel on The International Action Plan for the Radiation Protection of Patients
IAEA Headquarters, Vienna
22 - 24 March 2010
The Steering Panel of the International Action Plan for the Radiation Protection of Patients keeps under review the implementation of the activities listed in the plan, with a view to providing guidance – on a periodic basis – on the overall approach to the implementation of the Action Plan and to make proposals for adjustments, as may appear necessary. At its fourth meeting, the Steering Panel reviewed and evaluated the developments that have taken place since the third meeting in February 2008, and recommended future actions addressing emerging trends.
The Steering Panel also considered international developments affecting the radiation protection of patients, their effects (if any) on the Action Plan and potential necessary adjustments to the actions being expected from the participating organizations of the Action Plan.
The world’s annual per caput effective dose is increasing rapidly, nearly exclusively due to the increasing medical exposure, to the extent where it is now equal to or exceeding that from natural background in some countries. Contrary to other exposures to ionizing radiation, such as occupational exposure in nuclear installations, which have remained constant or decreased over the past decades, medical exposures have increased at a high rate. While much of this increase reflects positive developments, e.g. improved access to medical procedures using ionizing radiation, there is evidence that many diagnostic imaging procedures are unnecessary and many procedures are lacking in optimization.
Surveys have shown that there is a significant and systemic practice of inappropriate examination in radiology, leading to unnecessary exposures of many patients, thus highlighting the absolute necessity for improvements in justification of medical exposure of individuals. This issue requires effective solutions.
Medical technology using ionizing radiation is continuing to evolve rapidly, with new technology and techniques being introduced at a fast rate. This technology is now also increasingly reaching developing countries with less developed infrastructure. The worldwide annual sales of computed tomography (CT) scanners, has more than doubled since 1998 and is predicted to continue to increase at the same pace. CT-scanners now account for a very substantial fraction of dose to patients. Recent surveys in large medical centres have found that CT-examinations now often account for 10% to 35% of all examinations and 60% to 70% of the patient dose received from diagnostic radiology. The number of CT-installations, the frequency and type of CT-examinations, and the dose per examination are all increasing throughout the world. Moreover, patient surveys reveal a wide range of patient doses for the same examination, highlighting the continued necessity for improvements in optimization of medical exposure.
Increasing numbers of procedures are being performed using X rays to guide interventions in the body, and many of these procedures are performed to replace surgical interventions. Considerable patient exposure can occur in some of these procedures with potential for deterministic injuries, and there are also recent surveys showing an elevated risk for deterministic injuries in staff performing such procedures, making further optimization of radiation protection of patients and workers in this modality increasingly urgent.
Reports of unintended exposures in radiotherapy are also continuing to appear, not only involving overexposure of patients but also involving the systematic underexposure of large groups of patients. This highlights the continued need to strengthen international efforts on ensuring learning from past accidental exposures, as well as prospectively assessing safety in radiotherapy and implementing appropriate measures based on these assessments. In this approach to safety, radiotherapy can learn from high-reliability activities, such as nuclear installations.
International organizations and professional bodies continue to work together under the ongoing International Action Plan for the Radiation Protection of Patients, in order to strengthen the radiation protection in all medical applications of ionizing radiation.
- Once the revised BSS is published, appropriate actions should be undertaken to facilitate the implementation of the BSS requirements with respect to patient protection, including development of a Safety Guide providing elaboration on the requirements in the BSS.
- Form a group to examine the potential, uses and implementation of additional electronic social media that the IAEA is already using (Twitter, Facebook, Flickr, YouTube and mobile applications) for the RPoP website.
- To set up mini expert panels on specialized topics which can be consulted on an urgent basis to form position statements that can be disseminated through the RPoP website and through professional and social networks, as appropriate.
- Organizations participating in the international action plan should provide authenticated information to IAEA for inclusion on RPoP and create a link to RPoP.
- Continuation of the actions on educational reporting systems under development by the IAEA.
- Further efforts be taken to introduce radiation protection into undergraduate and postgraduate medical curricula.
- In educational programmes there should be an evaluation of use and explanations of the definitions of the terms protection of the patient, justification and optimization and the factors that compromise safety in radiotherapy. It would also be useful to develop a syllabus and an accompanying teaching course (primarily for Radiation Therapy Technologists - RTTs) in radiation protection of the patient in radiotherapy.
- An urgent international agreement on the staffing needs be prepared (medical, technologists and medical physicist) taking into account the kind of equipment, complexity of the procedures and expected workload. Such material would be necessary to be able to comply effectively with the requirements of the BSS.
- National regulations should enable and support the application of international IEC standards. Participants of scientific projects are encouraged to contribute actively to the development of equipment standards.
- Dose data in digital imaging should be made available in uniform and understandable manner for all modalities. The data provided should enable one to calculate effective dose. This will require cooperation between IEC, regulators and professional bodies. It is further recommended that the data be automatically displayed and stored with the images. In this manner, important clinical and dosimetry data remain linked and available for reporting, clinical decisions, tracking and analysis.
- Appropriate follow-up should be done on the findings and lessons/conclusions from the 2009 ASN Conference “Advances and challenges in radiation protection of patients”, particularly regarding new technologies: the need to have an evaluation system independent of the manufacturer.
- Research projects (or analysis of current research) should be encouraged on the evaluation of absorbed dose, optimization of protection and dose management in newer technology. The information should continue to be updated on the IAEA website. There should also be an evaluation of incidents and accidents associated with these new technologies. The system for estimation and recording of radiation dose to patients from the repeat high dose procedures should be established.
- Safety issues other than radiation safety (such as electrical and mechanical) and liability issues be considered in a draft document on second-hand equipment. The document published by the European Coordination Committee of the Radiological, Electromedical and Healthcare IT Industry (COCIR) “Good refurbishment practice for medical electrical equipment” may need to be referred and discussed in the draft document.
- To encourage the promotion of the use of evidence-based referral guidelines for radiation imaging.
- Strong emphasis should be placed on the periodic review and adjustment of reference levels in diagnostic radiology and interventional procedures as well as nuclear medicine, especially taking into account incoming data e.g. based on digital radiographic techniques.
- Centres should participate regularly in dosimetric inter-comparisons- External audits should be coordinated at the international and national level to prevent unnecessary duplication.
- Consideration of a group of experts to work towards consensus on unambiguous definitions for such common terms as prescription, treatment preparation, treatment delivery and verification; a high level process map for radiotherapy; and mapping between taxonomies so that data from a variety of electronic incident learning systems can at least be compared in a meaningful way to provide a greater opportunity to learn from global experience.
- There should be development of an International Campaign on justification of medical exposure in diagnostic imaging,being a collaborative effort of the key players and stakeholders. The campaign should initially focus on awareness among patients, public, relevant professionals, policy makers and media. Awareness must include appropriate balance of the benefits as well as the risks. Among the tools/solutions available are the 3A’s: Awareness, Appropriateness and Audit.
- A second international conference on radiation protection of patients should be organized. This would optimally be held in 2012 based upon issues regarding planning, venue and current interest. It should include the advances, challenges and opportunities in the field. There should also be input from multiple health professions using or prescribing ionizing radiation, as well as patients, regulators, policy-makers.