IAEA DRLs KAMPALA

Diagnostic Reference Levels

David Sutton / Colin Martin

Dundee & Glasgow

Kampla
 ICRP 73 1996

• First introduced the idea of a ‘diagnostic

reference level’
• Simple test for identifying situations where
levels of patient dose are unusually high

Kampla
 Application of DRLs
• Values of measured quantities above which
some specified action or decision should be
taken
–  Values must be specified
and
– Action must be specified

• DRLs will be intended for use as

a convenient test for identifying
situations where the levels of patient
dose are unusually high.

Kampla
 What is a Diagnostic Reference Level ?

• A dose level for typical examinations for

groups of standard-sized patients or
standard phantoms and for broadly
defined types of equipment
• A guide to the – indistinct – border
between good / normal practice and bad
/ abnormal practice
.

Kampla
What is a Diagnostic Reference Level ?

• Something set using an arbitrary (i.e. not

scientific) threshold in a distribution
• A trigger for the first ‘step in the
optimisation process
• A tool that serves as a means to identify
situations where patient doses are
unusually high

Kampla
 What are they NOT?
• Static : DRLs require continuous updating
• DRLs are not limiting (maximum) values; the
application of dose limits is not appropriate in
diagnostic radiology
• A carte blanche that
– image quality is appropriate
– the examination is performed at an optimized
dose level
• Surrogates for individual dose estimation

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 Diagnostic Reference Levels –Why?

• Radiation is harmful
• Diagnosis is beneficial
• Need to use the smallest amount of
radiation which will result in the correct
diagnosis.
• OPTIMISATION

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 Diagnostic Reference Levels –Why?

– Identify which dose is

just low enough &
what image quality is
just good enough to
achieve the required
diagnosis.

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 Diagnostic Reference Levels –Why?

– Identify which dose is

just low enough &
what image quality is
just good enough to
achieve the required
diagnosis.

Kampla
 Diagnostic Reference Levels –Why?

– Identify which dose is

just low enough &
what image quality is
just good enough to
achieve the required
diagnosis.

Kampla
 Diagnostic Reference Levels –Why?

– Identify which dose is

just low enough &
what image quality is
just good enough to
achieve the required
diagnosis.

Kampla
 Diagnostic Reference Levels –Why?

– Identify which dose is

just low enough &
what image quality is
just good enough to
achieve the required
diagnosis.

Kampla
 Diagnostic Reference Levels –Why?

– Identify which dose is

just low enough &
what image quality is
just good enough to
achieve the required
diagnosis.

Kampla
 Diagnostic Reference Levels –Why?

– Identify which dose is

just low enough &
what image quality is
just good enough to
achieve the required
diagnosis.

Kampla
 Diagnostic Reference Levels –Why?

– Identify which dose is

just low enough &
what image quality is
just good enough to
achieve the required
diagnosis.

Kampla
 Perceived image quality is task
and reader dependent.

Kampla
 Radiologist A

Radiologist B

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 50
100
20 mA
mA
200mA
150 mA
mA
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 Diagnostic Reference Levels –Why?

 What dose is just low

enough & what image
quality is just good
enough to achieve the
required diagnosis?

 Very Difficult to
do!!!

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 Diagnostic Reference Levels –Why?

– So lets just decide that if

the majority of
radiologists agree that a
particular dose produces
an image that’s
diagnostic then it
probably is.

- A guide to the – indistinct –

border between good /
normal practice and bad
/ abnormal practice.
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 Diagnostic Reference Levels –Why?
(Another possible reason)

• Regulatory Compliance
• Required under some National legislation;
Required by new BSS (John will talk about
the BSS)

Kampla
 Diagnostic Reference Levels

• A guide to the – indistinct – border

between good / normal practice and bad
/ abnormal practice.
• Based on the premise that images are
diagnostic in the first place .
• A step on the road to optimisation

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 Historical Perspective

– What is diagnostic ? :UK Survey of

Patient Dose 1984 -20 Hospitals
Examination Patient Ratio Room Ratio
Skull AP 19 5
Chest PA 48 11
T Spine AP 43 4
L Spine AP 71 11
Abdomen AP 88 8
Pelvis AP 37 5
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UK Survey of Patient Dose 1984

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 RCR “Patient Dose Reduction in Diagnostic
Radiology 1990”

• “Some 1300 man Sv could be saved by

persuading the 25% of hospitals with
the higher doses for the six exams to
change their technique to fall in line with
the remaining 75%”

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DRLS ARE OFTEN DEFINED BY
THE 75TH PERCENTILE

WHAT IS A PERCENTILE ?
 Data
1 10
2 9
3 8
4 27
5 17

Data
6 20
7 13
8 32 35
9 1
10 30
11 6 30
12 5
13 29
14 24 25
15 19
16 18
17 11 20
18 14
19 4
15
20 3
21 22
22 21 10
23 16
24 15
25 26 5
26 25
27 23
28 28 0
29 12 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32
30 7
31 2
32 31
Sample Number Data
1 1
2 2
3 3
4
5
4
5 Data
6 6 35
7 7
8 8
9 9 30
10 10
11 11
12 12 25
13 13
14 14
15 15 20
16 16
17 17
18 18 15
19 19
20 20
10
21 21
22 22
23 23 5
24 24
25 25
26 26 0
27 27 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32
28 28
29 29
30 30
31 31
32 32
 Data
35

30

25
Third Quartile
20
Median
15

10

0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32
Third Quartile
Sample Number Data
Different Data
1 1
2 1
3 3
4 4
5 5
6 6
7 7 Data
8 8
100
9 9
10 10 90
11 11
12 12 80
13 13
14 14 70
15 15
16 16 60
17 17
50
18 18
19 19 40
20 20
21 21 30
22 22
23 23 20
24 24
10
25 25
26 35 0
27 45 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32
28 55
29 65
30 75
31 85
32 95
 Some Data

Data
100

90

80

70

60

50

40

30 Third Quartile
Median
20

10

0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32
Third Quartile
 Data
120

100

80

60

Third Quartile
40

20
Median

0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32
Third Quartile
 Diagnostic Reference Levels

• Most easily understood at National i.e. –

very large sample – level
• 75th percentile chosen as the ‘indistinct
border” – No real scientific basis

(A guide to the – indistinct –

border between good /
normal practice and bad /
abnormal practice.)

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 National DRLs

• Usually set at 3rd quartile value from

distribution of hospital mean doses
• Excludes high dose ‘tail’ of distribution
• Expected to come down as equipment &
optimisation improve

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 Achievable Dose

• By definition, most centres will be below

the DRL.
• The median (50th percentile) of the
distribution used to set the DRL is called
the Achievable Dose.
• Achievable dose is a reasonable goal with
standard techniques and technologies.

Kampla
 UK Survey 2010

• January to December 2010

• 165,000 ESD measurements for
radiographs
• 185,000 KAP measurements for
radiographs
• 22,000 KAP measurements for
Fluoroscopy

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 UK Survey 2010

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 UK 75th percentiles : Radiography

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 UK 75th percentiles : Fluoroscopy

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 Quick Think

Why do you think that doses

have come down Since 1985?

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 How do you audit against DRLs in your
Hospital?

• Remember - A DRL is a dose level for

typical examinations for groups of
standard-sized patients or standard
phantoms and for broadly defined types
of equipment
• So decide which examinations you are
going to audit and in which faciility !!!! .

Kampla
 Some UK National Diagnostic Reference Levels

Skull Ba Swallow CT Head

Chest Ba Meal CT Chest
T Spine Ba Enema CT Abdomen
L spine IVU CT CA
Abdomen MCU ChestAbdoPelvis
Pelvis Pyelography
Bitewing Coronary Angio
L Ob Breast Venography
etc (Paediatric CT and
complete exams)

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 Do you have to audit against all the
National DRLs locally?

‘…NO’
It depends on what you do

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 Criteria for inclusion (1)

• Examinations must be performed

reasonably frequently in your hospital /
department and should be representatve of
all equipment.
• Data collection must be feasible

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 Criteria for inclusion (2)

• You should ideally include at least one

examination performed on each item of
equipment that makes a significant
contribution to the workload of the
department

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 Criteria for inclusion (3)

• Examinations should be inclusive with

regard to staff
• Examinations should ideally cover the
work of all groups of operators carrying out
procedures in the department, i.e. -
– radiographers
– radiologists
– non-radiological clinicians
– others
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 Auditing against DRLs

• Choose examinations that typify the

work of the hospital

• Don’t include more than you have to

• Don’t forget to close the audit loop

Kampla
 How to use DRLs - The first step

• You must have a dose monitoring

programme in place (and to set them in
the first place)
• Your dose monitoring programme
needn’t just measure strict dosimetric
quantities such as esd, CTDI or kap –
although preferable.
• Example : screening time during
pacemaker insertion (my view).
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 The Audit Spiral

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 How do you audit against DRLs

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 How do you audit against DRLs

• If a patient dose survey shows a DRL is

exceeded, you need to investigate why that
is. How do we decide if we have actually
exceeded a DRL because there are
uncertainties in all parts of the process..

Kampla
 How do you audit against DRLs
• One way assumes that a set of measured
patient doses would be considered to exceed
a DRL if their average was greater than the
DRL. Then the problem becomes one of
defining what is meant by ‘greater’.

• THERE IS UNCERTAINTY IN EVERYTHING

Kampla
 What is “greater than” (UK)

If the mean dose exceeds the DRL by

more than a defined proportion (e.g.
20%) and by at least 2 times the
standard error of the mean of the
local measurement then an
investigation is required as to why the
DRL has been exceeded.

This is ONE way – only a trigger

Kampla
 Example : dose audit AP Pelvis

• 5 Rooms
• DRL 3.9 mGy
Room N Mean SD SEM
ESD
R1 28 4.6 0.7 0.13
R2 21 3.7 0.6 0.15
R3 20 2.8 0.8 0.18
R4 10 5 1.2 0.38
R5 13 4.5 1.2 0.33
Kampla
3.9
 Example : dose audit AP Pelvis

• 5 Rooms
• DRL 3.9 mGy

Difference Mean - 2
Mean dose DRL from DRL SEM
Room (mGy) (mGy) (%)
R1 4.6 17.9 4.34
R2 3.7 -5.1 n/a
R3 2.8 3.9 -28.2 n/a
R4 5.0 25.6 4.24
R5 4.5 15.4 3.84

Kampla
 Dose audit Reveals that DRL has
been exceeded

Investigation Required

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 What is the investigation for ?

• The outcome of an investigation will be to

identify why the DRL has been exceeded.
• Remedial measures should be identified
and, where possible, acted upon prior to
recommencing the dose audit cycle.

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 The Audit Spiral

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 How do you audit against DRLs

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 What are the most likely factors to
consider if a DRL is exceeded?

• Measurement Methodology
• Equipment
• Case Mix
• Technique

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 1 Measurement Methodology

• In other words did you actually carry out

your dose audit in a sound manner that
was consistent with the way in which the
DRL was set in the first place?

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 Measurement Methodology

• TLDs calibrated appropriately and

background correction carried out correctly
?
• KAP meter calibrated correctly
– ? Undercouch tubes
– ? Spot imaging
• Calculation based on correct factors and
output measurements?

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 Measurement Methodology

• Was your dose audit carried out using the

same protocol that was used to derive the
data in the first place? – if not, reaudit.
• Example 1 National protocol
– Weight 70 +/- 5kg
– No patient <50 or > 90 kg

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 2 Equipment

• Is this likely to be the reason why a

National DRL is exceeded ?
• Possibilities
– Speed class ≤ 400
– Old II equipment
– ? CR DR
• Film Processing

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 Equipment

• Combination of CR /DR & conventional

• Differences in grid usage
• AEC mismatching
• Differing film screen combinations

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 3 Case Mix

• Certain areas may not be appropriate for

comparison with DRLs set for general population
– Paediatric Radiology
– CXRs in a chest clinic
– Expertise may lead to one cardiologist doing the
difficult cases
• Can justifiably exceed a DRL

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 4 Technique
• Q Should technique be the cause of
DRLs being exceeded in plain film
radiography ?
– Case mix
– Considerable agreement on what constitutes
good radiographic technique

• A I would like to think NOT!

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 Technique

• Q What about more ‘complex’ examinations ?

– It’s not reasonable to expect that all techniques will be
standardised

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 Technique

• A for the majority of procedures, technique is not

a good reason why a DRL should be exceeded.

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 Outcome – Equipment

• Findings reinforce what you expect to find

– Further support for replacement case
• Findings unexpected
– Critical review of QA and maintenance
programmes.

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 Outcome – Case mix

• If DRL exceeded because of case mix,

there is a sound case for not using the
DRL

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 Outcome – Technique

• Plain film
– Review SOPs
– Develop SOPs
• Fluoroscopy
– Complexity of investigation
– Unlikely to have DRLs for really complex examinations – most
should be suitable for SOPs
– No SOP, DRL exceeded?
• Question technique
• Critical review
• CT

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Kampla
 Outcome of investigation

• Identify why DRL exceeded

• Identify remedial measures
– Investigate ways of reducing doses
– Equipment factors
– Technique change
• Act, prior to recommencing audit cycle.

Kampla
 What is a DRL for (recap)

• DRL only triggers the first step in the

optimisation process.
• But it is a trigger that tells you where to
look and where to prioritise your effort.

Kampla
 In summary…

• Comparisons with DRLs at National Level can

be very useful in assessing patient doses &
indicating areas for optimization
• Be aware of uncertainties in the data (& in the
DRLs)
• Look at recorded technique data for indication of
why doses high (or low!)
• Be prepared to check methodology &
assumptions
Kampla
 Finally

• Diagnostic Image quality is the main

concern
• Don’t reduce dose so much that the
images become non diagnostic –
dose reduction is NOT a holy grail
• Many dose savings can be made
without affecting the image at all

Kampla