M e d i c a l P hy s i c s a n d I n f o r m a t i c s • O r i g i n a l R e s e a r c h

Kanal et al.
National Survey on Pediatric CT Head Examination Radiation
Dose

Medical Physics and Informatics

Original Research
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Variation in CT Pediatric Head

Kalpana M. Kanal1
Janessa M. Graves 2
Monica S. Vavilala1
Kimberly E. Applegate 3
Jeffrey G. Jarvik1
Frederick P. Rivara1
Kanal KM, Graves JM, Vavilala MS, Applegate KE,
Jarvik JG, Rivara FP
Keywords: CT, CT dose index volume, dose-length
product, pediatric head examination, radiation dose
DOI:10.2214/AJR.14.12997
Received April 12, 2014; accepted after revision
June 27, 2014.
K. M. Kanal received funding for this study from an
Education Research Development Grant from the
Radiological Society of North America, Association of
University Radiologists, Association of Program
Directors in Radiology, and Society of Chairmen of
Academic Radiology Departments. J. M. Graves received
fellowship support from the National Institute of Child
Health and Human Development (principal investigator
F. P. Rivara, T32 HD057822-01A2). This work was also
Examination Radiation Dose:
Results From a National Survey
OBJECTIVE. The purpose of this article is to examine the variation in radiation dose, CT
dose index volume (CTDIvol), and dose-length product (DLP) for pediatric head CT examina-
tions as a function of hospital characteristics across the United States.
MATERIALS AND METHODS. A survey inquiring about hospital information, CT
scanners, pediatric head examination protocol, CTDIvol, and DLP was mailed to a represen-
tative sample of U.S. hospitals. Follow-up mailings were sent to nonrespondents. Descrip-
tive characteristics of respondents and nonrespondents were compared using design-based
Pearson chi-square tests. Dose estimates were compared across hospital characteristics us-
ing Bonferroni-adjusted Wald test. Hospital-level factors associated with dose estimates were
evaluated using multiple linear regressions and modified Poisson regression models.
RESULTS. Surveys were sent out to 751 hospitals; 292 responded to the survey, of which
253 were eligible (35.5% response rate, calculated as number of hospitals who completed sur-
veys [n = 253] divided by sum of number who were eligible and initially consented [n = 712]
plus estimated number who were eligible among those who refused [n = 1]). Most respondents
reported using MDCT scanners (99.2%) and having a dedicated pediatric head CT protocol
(93%). Estimated mean reported CTDIvol values were 27.3 mGy (95% CI, 24.4–30.1 mGy),
and DLP values were 390.9 mGy × cm (95% CI, 346.6–435.1 mGy × cm). These values did
not vary significantly by region, trauma level, teaching status, CT accreditation, number of CT
scanners, or report of a dedicated pediatric CT protocol. However, estimated CTDIvol report-
ed by children’s hospitals was 19% lower than that reported by general hospitals (p < 0.01).
CONCLUSION. Most hospitals (82%) report doses that meet American College of Radi-
ology accreditation levels. However, the mean CTDIvol at children’s hospitals was approximate-
ly 7 mGy (21%, adjusted for covariates), lower than that at nonchildren’s hospitals.

supported by the Harborview Injury Prevention &
Research Center, University of Washington. J. G. Jarvik
is a stockholder of PhysioSonics, a consultant for
HealthHelp, and a coeditor of Springer Science+Business
Media Deutschland.
1
Department of Radiology, University of Washington,
1959 NE Pacific St, Seattle, WA 98195. Address
correspondence to K. M. Kanal (kkanal@uw.edu).
2
Washington State University College of Nursing,
Spokane, WA.
3
Department of Radiology and Imaging Sciences, Emory
University School of Medicine, Atlanta, GA.
WEB
This is a web exclusive article.
AJR 2015; 204:W293–W301
0361–803X/15/2043–W293
© American Roentgen Ray Society
C
T technology has changed signifi-
cantly with the availability of
modern MDCT scanners, which
are technically complex, faster,
and more accessible, but may have an associat-
ed increase in radiation dose [1–8]. The Nation-
al Council on Radiation Protection estimates
that, in 2006, 67 million CT scans accounted
for 15% of the total medical radiation proce-
dures and about 50% of the collective dose,
thus being the single and largest source of med-
ical radiation in the United States [4]. This
number increased to approximately 85 million
in 2011 [9], with 5–11% of these scans being
performed on children [1, 4, 10, 11].
The most common body part scanned in
children is the head, and the most common
indication is for trauma. CT is used to diag-
nose and manage traumatic brain injury in
children because it is readily available, fast,
and sensitive in identifying injuries that re-
quire immediate intervention in an acute care
setting, such as the emergency department.
However, the increase in CT use has led to
increased concern about its concomitant ra-
diation dose, especially among children [12].
This issue has been the topic of several stud-
ies as well as media attention in recent years
[12–15]. The 2013 United Nations Scientific
Committee on the Effects of Atomic Radia-
tion report on the effects of radiation expo-
sure of children states that children may re-
ceive significantly higher doses than adults
for the same examination if the technical pa-
rameters are not specifically adapted [16].
In 2009, King and colleagues [17] found
variations in pediatric head CT doses across
dedicated and nondedicated children’s hospi-
tals. Such disparities are concerning, because
variations in medical care have been shown

AJR:204, March 2015 W293


Sampled hospitals
n = 751
Ineligible
n = 38
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Refusals
n=1
Eligible
n = 712
Nonrespondents
n = 459
Responded to survey
n = 253 (35.5%)
Completed dose questions
n = 179 (70.8% of respondents)
Fig. 1—Response rate calculation for national
pediatric head CT survey (using Council of American
Survey Research Organizations formula). Response
rate was number of hospitals who completed surveys
(n = 253) divided by sum of number who were eligible
and initially consented (n = 712) plus estimated
number who were eligible among those who refused
(n = 1), or 253 / (712 + 1) = 35.5%.
to be associated with poor outcomes [18]. In
2008–2009, a study of Washington State trau-
ma centers showed variation in the use of pe-
diatric head CT protocols, dose-reduction op-
tions, and estimated dose for pediatric head CT
scans across trauma levels [19]. A follow-up
study in 2012 showed that a large variation in
pediatric head CT dose remained [20]. Consis-
tent imaging protocols and adjustment of CT
settings based on clinical indication and size
of the child may reduce variation and radiation
exposure from medical imaging. In 2008, the
Image Gently campaign was launched to edu-
cate and encourage adoption of child-specific
protocols when CT is used [21–23]. Justifica-
tion and optimization of CT especially in the
emergency department is also important [24].
In this study, we conducted a national-
ly representative survey of U.S. community
hospitals to examine the variation in esti-
mated radiation dose, CT dose index volume
(CTDIvol), and dose-length product (DLP)
[25] for a pediatric head CT examination as
a function of hospital characteristics.
Materials and Methods
Survey Design
We developed a mixed mode (paper and online)
survey with sections gathering hospital information,
W294
Kanal et al.
CT scanner information, pediatric head examination
protocol scan parameters, displayed CTDIvol and
DLP, and shielding information (Appendix 1).
Sampling and Administration
A stratified random sample of 623 communi-
ty hospitals was selected from the 5429 commu-
nity hospitals in the American Hospital Associ-
ation (AHA) 2010 Annual Survey database [26].
The AHA defines community hospitals as “all
nonfederal, short-term general, and other special
hospitals [27],” including academic medical cen-
ters and teaching hospitals (so long as they are
nonfederal). Hospitals that are not accessible by
the general public are not considered community
hospitals (e.g., college infirmaries and prison hos-
pitals). Census region, bed size, and trauma level
were the criteria used to generate sampling strata.
To oversample institutions with service primar-
ily to children, an additional 129 hospitals were
added to the sample, of which the information for
52 hospitals was available through the AHA da-
tabase. For the remaining 77 hospitals, hospital-
level information was obtained by contacting the
hospitals directly or doing a web search. The final
survey sample included 751 hospitals.
Surveys were mailed and addressed to the
lead CT technologist in the Department of Ra-
diology. Contact names were ascertained for a
random sample of hospitals (n = 287) through
web searches or by calling hospitals directly.
(For the remaining 464 hospitals, we directed
mailings to the “Lead CT Technologist.”) Each
mailing included a self-addressed stamped en-
velope for responses. A number of nonrespond-
ing hospitals were also contacted electronical-
ly by obtaining the e-mail address of the lead
CT technologist on the web. E-mails were sent
at frequencies similar to those of the paper mail-
ings. Respondents were given the option to com-
plete the survey online. Follow-up mailings (up
to four reminders) were sent approximately 2–4
25
Responding Hospitals (%)
20
15
10
5
0
0 20
CTDIvol (mGy) for Head CT of Female Infant (0–1 y Old)
weeks apart to nonrespondents. Incentives, in-
cluding a $10 retail gift card and raffle entry for
an iPad Mini (Apple), were offered to the first
respondent from each institution. If more than
one response was received from a single institu-
tion, only the first response was used. The sur-
veys were sent out and responses documented
from October 2012 to June 2013. This study was
exempt from ethics review by our institutional
review board because the survey inquired about
institutional and not individual practices.
Hospital Data
We acquired the following information from
the AHA 2010 Annual Survey database [26]:
trauma level (regional, community, rural, or
nontrauma center), bed size (0–50 beds, 51–150
beds, or > 150 beds), region (Northeast, South,
Midwest, or West), service (children’s or gener-
al hospital), location (urban or rural), and teach-
ing status. Hospital rurality was determined us-
ing Core Based Statistical Areas; metropolitan or
division statistical area hospitals were considered
urban, and micropolitan or rural area hospitals
were considered rural. Hospitals were considered
teaching hospitals if they met one of the follow-
ing criteria: any residency training program ap-
proved by the Accreditation Council for Graduate
Medical Education, medical school affiliation to
the American Medical Association, or member of
the Council of Teaching Hospitals of the Associa-
tion of American Medical Colleges. To determine
whether a hospital was accredited by the Amer-
ican College of Radiology (ACR) CT accredi-
tation for either general or pediatric CT (Image
Gently), we cross-referenced the list of hospitals
in our sample with the Accredited Facility Search
on the ACR website [28].
ACR pediatric CT accreditation standards indi-
cate that the maximum acceptable phantom CTDI-
vol dose for a pediatric head CT is 40 mGy (for a
1-year-old child) [29]. Therefore, we dichotomized
Fig. 2—Volume CT
dose index (CTDIvol) for
head CT scan of female
infant as reported by
respondent institutions
40 60 80 (n = 179). Values indicate
actual reported values,
not weighted estimates.
AJR:204, March 2015
 National Survey on Pediatric CT Head Examination Radiation Dose

TABLE 1: Characteristics of Sampled Hospitals, Respondents, and Nonrespondents

Respondents
Nonrespondents (n = 459)
Characteristics Eligible (n = 253) Ineligible (n = 38) and Refusals (n = 1) Total Sample (n = 751)
Regiona
Northeast 48 (15) 3 (5) 96 (13) 147 (13)
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Midwest 60 (29) 13 (38) 107 (30) 180 (30)

South 69 (28) 11 (23) 185 (43) 265 (38)
West 76 (28) 11 (34) 72 (14) 159 (19)
Service
General hospital 197 (95) 36 (99) 385 (97) 618 (97)
Children’s hospital 56 (5) 2 (1) 75 (3) 133 (3)
Trauma levela
Regional trauma center 72 (12) 7 (9) 111 (8) 190 (9)
Community trauma center 49 (11) 6 (8) 105 (11) 160 (11)
Rural trauma centerb 7 (29) 10 (22) 98 (15) 180 (19)
Nontrauma center 60 (48) 15 (61) 146 (66) 221 (61)
Teaching statusc
Nonteaching 154 (66) 29 (81) 328 (69) 511 (31)
Teaching 99 (34) 9 (19) 132 (31) 240 (69)
Estimated emergency department volume (annual visits)a
≤ 5000 16 (11) 11 (51) 47 (18) 74 (18)
5001–15,000 51 (29) 10 (16) 88 (21) 149 (23)
15,001–50,000 105 (39) 10 (21) 177 (40) 292 (38)
≥ 50,001 60 (19) 5 (11) 94 (20) 159 (19)
Unknownd 21 (2) 2 (1) 54 (2) 77 (2)
ACR CT accreditatione
No 133 (57) 23 (66) 271 (63) 427 (61)
Yes 120 (43) 15 (34) 189 (37) 324 (39)
ACR pediatric CT accreditatione
No 141 (59) 29 (81) 290 (67) 460 (66)
Yes 112 (41) 9 (19) 170 (33) 291 (34)
Note—Data are number (weighted percentage). ACR = American College of Radiology.
aSignificant difference between groups, based on weighted results, design-based Pearson chi-square test, p < 0.05.
bA hospital located in a metropolitan statistical area is considered urban, and one in a nonmetropolitan statistical area is rural.
cA hospital is considered a teaching hospital if it has a residency training program approved by the Accreditation Council for Graduate Medical Education, has medical

school affiliation reported to the American Medical Association, or is a member of the Council of Teaching Hospital of the Association of American Medical Colleges.
dEmergency department volume was not available for 77 children’s hospitals.
eBased on Accredited Facility Search on the ACR website.

hospitals into two groups according to whether their
reported CTDIvol value exceeded the standard.
Analysis
This study involved three main goals: describe
the variation in CTDIvol and DLP across hospital
characteristics, evaluate the estimated difference
in CTDIvol and DLP across hospital characteris-
tics, and explore hospital-level factors associated
with having CTDIvol over 40 mGy.
All analyses were conducted using weighted sur-
vey methods (svy commands) in Stata/SE statistical
software (version 11.2, StataCorp). Sampling weights
were used to account for the stratified random sample
survey design and to adjust survey results to represent
the larger sample of U.S. community and children’s
hospitals. Descriptive characteristics of respondents
and nonrespondents were compared using design-
based Pearson chi-square tests. CTDIvol and DLP es-
timates were compared across hospital characteristics
using Bonferroni-adjusted Wald tests (using survey-
weighted values).
To evaluate the estimated mean difference
in CTDIvol for pediatric head CT as a function
of hospital characteristics, we conducted multi-
variable linear regression analyses. The mean
dose estimates were weighted for survey design.
Unadjusted models include the single predictor of
interest (e.g., region); the adjusted model includes
all hospital characteristics. Coefficients in the ad-
justed models indicate the estimated mean differ-
ence in CTDIvol for an institution in one category
compared with the reference group while holding
all other institutional characteristics constant.
We compared the proportion of hospitals ex-
ceeding the ACR maximum acceptable phantom

AJR:204, March 2015 W295

 Kanal et al.

dose using design-based Pearson chi-square tests. TABLE 2: Mean Values for Dose Measures Among Respondents, Adjusted to
We then used modified Poisson regression [30] to Account for Survey Weights
evaluate the hospital-level factors associated with
CTDIvol (mGy) DLP (mGy × cm)
exceeding this threshold. Results from modified
Poisson regression describe the estimated likeli- Characteristic Mean (95% CI) pa Mean (95% CI) pa
hood of a hospital having a CTDIvol that exceeds Total (n = 179) 27.3 (24.4–30.1) 390.9 (346.6–435.1)
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the ACR standard, based on its characteristics.

Region 0.53 0.22
The adjusted model includes all possible predic-
tors of interest, whereas the unadjusted models Northeast 24.1 (19.0–29.1) 324.3 (264.8–383.8)
evaluate hospital characteristics independently. Midwest 27.4 (22.1–32.7) 450.5 (341.9–559.1)
South 29.2 (23.4–35.0) 381.3 (309.6–452.9)
Results
West 26.5 (21.3–31.8) 369.0 (302.8–435.2)
Response Rate and Hospital Characteristics
Surveys were sent out to 751 hospitals in Service < 0.01 < 0.01
our sample; 292 hospitals responded to the General hospital 27.6 (24.5–30.6) 395.1 (348.2–442.1)
survey, of which 253 were eligible. Reasons Children’s hospital 22.3 (21.3–23.3) 319.3 (304.2–334.4)
for ineligibility included not scanning chil-
Trauma level 0.93 0.99
dren 0–1 year old (n = 16), not having a CT
scanner (n = 15), not seeing pediatric pa- Regional trauma center 29.1 (26.7–31.5) 388.8 (343.3–434.4)
tients (n = 4), hospital closed (n = 2), and not Community trauma center 28.1 (24.0–32.2) 405.9 (289.3–522.4)
seeing trauma patients (n = 1). The response Rural trauma center 28.6 (22.3–35.0) 393.2 (318.5–468.0)
rate for the survey was 35.5% (Fig. 1).
Nontrauma center 25.6 (21.2–30.1) 385.9 (307.8–464.0)
Eligible respondent hospitals were similar
to the total sample with regard to ACR CT Teaching status 0.60 0.21
accreditation and ACR Image Gently CT ac- Nonteaching 26.3 (22.6–30.1) 368.3 (317.4–419.2)
creditation but differed for all other charac- Teaching 28.9 (24.7–33.2) 430.5 (347.7–513.2)
teristics, such as region, trauma level, teach-
Reported pediatric protocol 0.67 0.40
ing status, general versus children’s hospital,
emergency department volumes, and trau- No dedicated protocol 30.8 (17.1–44.6) 466.0 (290.1–641.9)
ma level (Table 1). The least number of re- Dedicated protocol 27.0 (24.0–30.0) 387.7 (341.4–433.9)
sponses came from the Northeast region of ACR CT accreditation 0.89 0.74
the country. About 44.5% of the respondents
reported having one CT scanner, where- No 26.6 (23.2–29.9) 397.1 (335.2–459.1)
as 55.5% of the respondents reported hav- Yes 28.2 (23.3–33.1) 382.3 (321.1–443.4)
ing two or more scanners. Most respondents ACR pediatric CT accreditation 1.00 0.30
reported scanners being MDCT scanners No 26.8 (23.6–30.1) 409.0 (345.7–472.3)
(99.2%). Most respondents reported having a
dedicated pediatric head CT protocol (93%). Yes 37.9 (22.8–33.0) 364.2 (308.2–420.1)
No. of CT scanners 0.06 0.17
CT Dose Index Volume and Dose-Length Product 1 27.9 (23.6–32.2) 408.8 (342.5–475.1)
The survey asked respondents to report
2 23.6 (20.7–26.4) 333.1 (277.0–389.2)
on the console-displayed CTDIvol (in milli-
grays) and DLP (in milligrays times centi- >2 29.7 (23.0–36.3) 407.8 (314.3–501.4)
aSignificance based on Bonferroni-adjusted (where applicable) Wald test on weighted values.
meters). Of the 253 responding and eligible
hospitals, 179 (70.8%) reported sufficient
CTDIvol and DLP information. The estimat- distribution of reported CTDIvol values (un- hospital-level factors except for service and
ed mean CTDIvol and DLP were 27.3 mGy weighted) among the 179 respondents. number of CT scanners (Table 3).
(95% CI, 24.4–30.1 mGy) and 390.9 mGy × Of 73 institutions with ACR accreditation The estimated mean CTDIvol reported by
cm (95% CI, 346.6–435.1 mGy × cm), re- at the time of survey, the reported CTDIvol children’s hospitals was 7 mGy (95% CI, 4.47–
spectively. Estimated mean CTDIvol and exceeded the current ACR accreditation pe- 9.53 mGy) lower than that reported by non-
DLP values did not vary significantly by re- diatric head examination pass criteria for 13 children’s hospitals, after adjusting for all oth-
gion, trauma level, teaching status, CT ac- (18%). Among the 68 hospitals with ACR er institutional characteristics. Hospitals with
creditation, number of CT scanners, or re- pediatric CT accreditation, 11 (16%) report- two CT scanners for pediatric head CT report-
port of a dedicated pediatric CT protocol ed CTDIvol values that exceeded the current ed a CTDIvol 10.17 mGy (95% CI, 3.17–17.22
(Table 2). The adjusted estimated mean CT- ACR accreditation pediatric head examina- mGy) lower than that for hospitals with a single
DIvol and DLP were statistically significant- tion pass criteria standard. CT scanner for pediatric head CT, after adjust-
ly lower in children’s hospitals than general Linear regression analyses indicate that ing for covariates. No association was observed
hospitals (p < 0.01). Figure 2 illustrates the estimated mean CTDIvol does not vary across for institutions with more than two CT scanners.

W296 AJR:204, March 2015

 National Survey on Pediatric CT Head Examination Radiation Dose

Maximum Acceptable Phantom Dose CT Dose TABLE 3: Difference in CT Dose Index Volume (in Milligrays) Across Levels
Index Volume Over 40 mGy of Scanner Type, Protocol Use, or American College of Radiology
Among respondents who reported CTDIvol (ACR) Accreditation, Adjusted for Hospital Characteristics
information, unweighted estimates for the
Unadjusted Adjusted
majority (83%, n = 149) were equal to or be-
low the current ACR accreditation pediatric Characteristic Coefficient (95% CI) p Coefficient (95% CI) p
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head examination pass criteria standard of Region

40 mGy (Table 4). The number of hospitals
Northeast −4.66 (−12.70 to 3.38) 0.26 −7.64 (−16.19 to 0.91) 0.08
reporting CTDIvol greater than 40 mGy was
statistically significantly higher for general Midwest −1.39 (−9.68 to 6.91) 0.74 −3.13 (−11.87 to 5.61) 0.48
hospitals compared with children’s hospi- South 0.42 (−8.19 to 9.04) 0.92 5.31 (−7.15 to 10.10) 0.74
tals (p = 0.04). Modified Poisson regression West Reference Reference
models suggest that there are no statistical-
Service
ly significant associations between hospital-
level characteristics and the likelihood of an General hospital Reference Reference
institution reporting a CTDIvol for pediatric Children’s hospital −5.34 (−8.74 to −1.94) < 0.01 −6.99 (−9.53 to −4.47) < 0.01
head CT that exceeds the current ACR ac- Trauma level
creditation pediatric head examination pass
Regional trauma center Reference Reference
criteria standard (> 40 mGy).
Community trauma center −0.64 (−5.26 to 3.97) 0.78 1.84 (−3.03 to 6.71) 0.46
Discussion Rural trauma center −0.41 (−7.07 to 6.25) 0.90 −4.49 (−12.40 to 3.43) 0.27
In this survey, most reported doses for the Nontrauma center −1.93 (−7.70 to 3.83) 0.51 −4.87 (−12.56 to 2.82) 0.21
pediatric head examination were lower than the
Teaching status
ACR accreditation limit of 40 mGy [29]. Re-
spondents provided sufficient information for Nonteaching Reference Reference
the dose-related questionnaire items, which Teaching 1.56 (−4.24 to 7.37) 0.60 3.96 (−0.81 to 8.74) 0.10
may have been because we asked facilities to Reported pediatric protocol
report the displayed CTDIvol and DLP from
No dedicated protocol 3.01 (−10.82 to 16.84) 0.67 9.24 (−2.40 to 20.89) 0.12
the console, rather than asking for the techni-
cal scan parameters, which was our approach Dedicated protocol Reference Reference
in previous surveys [19, 20]. The main find- ACR pediatric CT accreditation
ing of this survey was that, although the mean No Reference Reference
CTDIvol and DLP values did not vary signifi-
Yes −0.01 (−6.23 to 6.20) 1.00 2.51 (−4.39 to 9.42) 0.48
cantly as a function of many hospital charac-
teristics, estimated dose did vary significantly Number of scanners
when comparing general hospitals versus dedi- 1 Reference Reference
cated children’s hospitals. The estimated mean 2 −5.40 (−10.80 to 0.00) 0.05 −10.17 (−17.22 to −3.12) < 0.01
CTDIvol values reported by children’s hospitals
>2 −0.71 (−7.30 to 8.71) 0.86 −3.03 (−12.12 to 6.06) 0.51
were approximately 7 mGy lower than those
for nonchildren’s hospitals, after adjusting for Constant 33.21 (21.77–44.65)
covariates. This finding suggests that children’s
hospitals may have a higher level of awareness atric head CT protocol, a finding similar to our median CTDIvol of 33 and 31 mGy, respec-
of tailored CT protocols for pediatric popula- previous research [32]. Together, these studies tively, for an unenhanced pediatric head ex-
tions. This result corresponds with the results suggest that conventional single-detector CT amination for children 0–2 years old for all
of our previous research in Washington State, scanners are becoming less common, a sign the facilities participating in the dose registry
where pediatric-designated centers had lower that U.S. hospitals are adopting the modern [33]. For metropolitan hospitals, these values
doses and used statistically significantly lower MDCT technology with its dose reduction op- were 31 and 29 mGy, respectively [33]. The
scan parameters than adult-designated centers tions—mainly, automatic tube current modu- average CTDIvol and DLP values reported by
[19, 20]. Borders and colleagues [31] reported lation—and iterative reconstruction methods the ACR accreditation program for pediatric
that greater compliance and significantly re- [6, 7, 17, 19, 20–23]. head examination (for a 1-year-old child, for
duced patient dose are possible when imaging Among U.S. community hospitals, the September 2012 through September 2013)
pediatric patients with dedicated pediatric CT mean reported CTDIvol in this survey was are 28.3 mGy and 340.3 mGy × cm (unpub-
technologists in a dedicated pediatric imaging 27.3 mGy, which is lower than the current lished data, ACR, December 2013), which
department. They further suggest that greater ACR accreditation pediatric head examina- agree very well with our data.
scrutiny may be required for departments that tion CTDIvol pass criterion (40 mGy for a As already noted, the ACR accredita-
scan both children and adults [31]. 1-year-old child), which went into effect on tion pass criterion of 40 mGy is a recent re-
Most survey respondents reported having July 1, 2013. The ACR Dose Index Registry quirement. There is no requirement for DLP.
MDCT scanners and using a dedicated pedi- reported for 2013’s fourth quarter a mean and We dichotomized reported (unweighted)

AJR:204, March 2015 W297

 Kanal et al.

TABLE 4: CT Dose Index Volume (CTDIvol) > 40 mGy Across Hospital reported estimated CT scan parameters for a
­Characteristics (Maximum Acceptable Phantom Dose for a hypothetic pediatric patient with head trau-
­Pediatric Head CT, According to American College of Radiology ma. Actual CT dose data were not reviewed.
[ACR] Pediatric CT Accreditation Standards) Future research, using postscan dose esti-
Characteristic CTDIvol ≤ 40 mGy (n = 149) CTDIvol > 40 mGy (n = 30) pa mates, should be conducted to evaluate the
variations observed in this study. We plan to
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Region 0.73
do so using the ACR’s Dose Index Registry
Northeast 26 (13) 4 (9) to compare with these results.
Midwest 38 (30) 5 (20) Results from this nationally representa-
South 37 (27) 12 (35)
tive survey suggest that children’s hospitals
may have significantly lower estimated mean
West 48 (29) 9 (35)
CTDIvol values than general hospitals. The
Service 0.04 estimated mean CTDIvol among U.S. com-
General hospital 108 (94) 25 (97) munity hospitals was 27. 3 mGy.
Children’s hospital 41 (6) 5 (3)
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(Appendix starts on next page)
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 Kanal et al.

APPENDIX 1: Understanding Protocols for Pediatric Head CT: National Hospital Survey
Thank you for completing this survey that will help us understand the use of protocols for head CT scans among pediatric trauma patients in
U.S. hospitals.

1. Hospital information
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Your hospital name

(Please do not use abbreviations) ______________________________________
(Write in)
Your hospital city and state
______________________________________
(Write in)
Your e-mail address
(Necessary to receive $10.00 E-Gift card and for raffle entry for iPad mini) ______________________________________
(Write in)
E-Gift card choice o $10.00 Amazon.com gift card
(Please indicate which gift card you would prefer. Check one box.) o $10.00 Starbucks gift card
What is the number of CT scanners that are on site at your hospital? o 0
(Check one box) o 1
o 2
o 3 or more
Does your hospital perform head CT scans on 0–1-year-old children being o Yes
seen for trauma? o No
Does your hospital have a dedicated protocol for a pediatric trauma patient o Yes Ž Year implemented: _________________________________
having a head CT scan? o No
o Do not know

2. CT scanner information
For the CT scanner most often used for scanning heads of pediatric patients between 0 and 1-year-old, please answer the following questions:
What is the name of the CT manufacturer and model? (Check one box from the list below)
o GE Healthcare - LightSpeed HD750 o Siemens - Definition AS
o Siemens - Sensation 64
o GE Healthcare - LightSpeed VCT o Siemens - Sensation Open
o Siemens - Sensation 10
o GE Healthcare - LightSpeed RT o Siemens - Emotion 6
o GE Healthcare - LightSpeed Pro 16 o Siemens - Sensation 16 Straton
o GE Healthcare - LightSpeed 16 o Siemens - Sensation 16
o GE Healthcare - LightSpeed Ultra o Siemens - Sensation 4
o Toshiba - Aquilion 16
o GE Healthcare - QX/I, LightSpeed, LightSpeed Plus o Toshiba - Asteion Dual
o Toshiba - Asteion Multi (CXB-400C tube)
o General - Electric HiLight, HighSpeed, CT/i
o Toshiba - Asteion Multi (old tube)
o Philips Healthcare - Brilliance 64 or 40
o Philips Healthcare - Big Bore o Toshiba - Auklet
o Philips Healthcare - Aura o Toshiba - Aquilion Multi /4
o Philips Healthcare - Brilliance 16 o Toshiba - Xpress GX
o Philips Healthcare - AcQSim o Toshiba - Xpress HS
o Philips Healthcare - Mx8000 o Other
o Philips Healthcare - Secura ____________________________________
o Philips Healthcare - TX (Write in)
Is this scanner a single or MDCT? o Single
o Multidetector Ž Number of channels: _______
o Do not know
Is this scanner accredited by American College of Radiology or another o Yes Ž When, and by which agency: (Write in)
accreditation body?
______________________________
o No
o Do not know
(Appendix 1 continues on next page)

W300 AJR:204, March 2015

 National Survey on Pediatric CT Head Examination Radiation Dose

APPENDIX 1: Understanding Protocols for Pediatric Head CT: National Hospital Survey (continued)

3. Scanning pediatric head trauma: Radiation dose display from CT console

Please provide the information below as it would pertain to a pediatric patient between 0 and 1-year-old receiving a head scan.
Review the next four questions in this section. Do you have sufficient o Yes Ž Continue & answer the questions below.
information to answer these questions?
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o No Ž Skip to section 4.
CTDIvol (For example: 25 mGy, 70 mGy) ____________________ mGy
Phantom indicated on console o 16 cm
o 32 cm
DLP (For example: 700 mGy * cm, 470 mGy * cm) ____________________ mGy * cm
Ž Please continue to section 5.

4. Scanning pediatric head trauma: Protocol scan parameters

If you are not able to fill in information in section 3, please provide the typical scan parameters that would be used for a pediatric patient between 0 and 1-year-old
receiving a head scan.
Kilovoltage (kV) (For example: 120 kV) ____________________ kV
Tube current (mA) (For example: 300 mA or average mA if using automatic tube ____________________ mA
current modulation)
Rotation time (s) (For example: 0.5 s, 1.0 s) ____________________ s
Scan mode o Axial
o Helical Ž Pitch: ____________
Effective mAs (mA/pitch), if applicable
Total beam collimation for scan acquisition
(For example: 0.625 mm × 64 channels (40 mm),
5 mm × 4 channels (20 mm),
5 mm × 2 channels (10 mm)) ________ mm × _____ channels (_____ mm)
Anatomy scan range (For example: Top of head to base of head; Top of head __________________________________ (Write in)
to shoulders)

5. Protective shielding
Does your hospital use external (lead or bismuth) shielding to protect organs o Yes
during head CT scans?
o No.
o Do not know
Which organs are shielded? (Check all that apply) o Eyes
o Thyroid
o Other
____________________________________
(Write in)

AJR:204, March 2015 W301