Pediatric Radiology

, Volume 45, Issue 2, pp 228–234 | Cite as

Implementation of a competency check-off in diagnostic fluoroscopy for radiology trainees: impact on reducing radiation for three common fluoroscopic exams in children

  • Sweta Shah
  • Stephane L. DesouchesEmail author
  • Lisa H. Lowe
  • Nima Kasraie
  • Brenton Reading
Original Article



Fluoroscopy is an important tool for diagnosis in the pediatric population, but it carries the risk of radiation exposure. Because radiology resident education and experience in the use of fluoroscopy equipment in children vary, we implemented an intervention to standardize fluoroscopy training.


The purpose of this study is to determine the impact of implementing a fluoroscopy competency check-off for radiology resident trainees aimed at decreasing radiation exposure in three common pediatric fluoroscopic studies.

Materials and methods

A fluoroscopy competency check-off form was developed for radiology resident trainees performing pediatric procedures. Techniques used to limit radiation exposure for common pediatric radiologic studies were reviewed as part of the check-off process. Pediatric radiologists supervised each trainee until they demonstrated competence to independently perform three specified procedures. Radiation dose was recorded for the three procedures, upper GI (UGI), voiding cystourethrogram (VCUG) and oropharyngeal (OPM) exams, over 6 months preceding and 6 months following implementation of the competency check-off. The mean cumulative dose for each procedure was compared before and after implementation of competency check-off using a Kruskal-Wallis test.


During the 12-month study period doses from 909 fluoroscopic procedures were recorded. In the 6 months preceding competency check-off implementation, procedures were performed by 24 radiology resident trainees including 171 UGI, 176 VCUG and 171 OPM exams. In the 6 months following competency check-off, 23 trainees performed 114 UGI, 145 VCUG and 132 OPM exams. After competency check-off implementation, a statistically significant reduction in average radiation dose was found for all three studies (P < 0.001). Median cumulative doses (mGy) were decreased by 33%, 36% and 13% for UGIs, VCUGs and OPMs, respectively.


Implementation of a competency check-off for radiology resident trainees can reduce average radiation doses in pediatric patients undergoing three common fluoroscopic studies.


Radiation exposure Fluoroscopy Children Radiology resident Training Cumulative dose 


Conflicts of interest



  1. 1.
    Sheyn DD, Racadio JM, Ying J et al (2008) Efficacy of a radiation safety education initiative in reducing radiation exposure in the pediatric IR suite. Pediatr Radiol 38:669–674PubMedCrossRefGoogle Scholar
  2. 2.
    Xu BJ, Duszak R Jr, McGinnis RS et al (2013) Increased fluoroscopy time for central venous catheter placement by radiology residents versus staff radiologists. J Am Coll Radiol 10:518–522PubMedCrossRefGoogle Scholar
  3. 3.
    Cohen BL (2002) Cancer risk from low-level radiation. AJR Am J Roentgenol 179:1137–1143PubMedCrossRefGoogle Scholar
  4. 4.
    Haaga JR (2001) Radiation dose management: weighing risk versus benefit. AJR Am J Roentgenol 177:289–291PubMedCrossRefGoogle Scholar
  5. 5.
    Brenner D, Elliston C, Hall E et al (2001) Estimated risks of radiation-induced fatal cancer from pediatric CT. AJR Am J Roentgenol 176:289–296PubMedCrossRefGoogle Scholar
  6. 6.
    Goske MJ, Applegate KE, Boylan J et al (2008) The Image Gently campaign: working together to change practice. AJR Am J Roentgenol 190:273–274PubMedCrossRefGoogle Scholar
  7. 7.
    Connolly B, Racadio J, Towbin R (2006) Practice of ALARA in the pediatric interventional suite. Pediatr Radiol 36:163–167PubMedCentralPubMedCrossRefGoogle Scholar
  8. 8.
    Donnelly LF (2005) Reducing radiation dose associated with pediatric CT by decreasing unnecessary examinations. AJR Am J Roentgenol 184:655–657PubMedCrossRefGoogle Scholar
  9. 9.
    Strauss KJ, Kaste SC (2006) The ALARA concept in pediatric interventional and fluoroscopic imaging: striving to keep radiation doses as low as possible during fluoroscopy of pediatric patients–a white paper executive summary. AJR Am J Roentgenol 187:818–819PubMedCrossRefGoogle Scholar
  10. 10.
    Strauss KJ, Kaste SC (2006) The ALARA (as low as reasonably achievable) concept in pediatric interventional and fluoroscopic imaging: striving to keep radiation doses as low as possible during fluoroscopy of pediatric patients–a white paper executive summary. Radiology 240:621–622PubMedCrossRefGoogle Scholar
  11. 11.
    American College of Radiology, RSNA, American Society of Radiologic Technologists, American Association of Physicists in Medicine (2010) Image Wisely. American College of Radiology, RestonGoogle Scholar
  12. 12.
    Brink JA, Amis ES Jr (2010) Image Wisely: a campaign to increase awareness about adult radiation protection. Radiology 257:601–602PubMedCrossRefGoogle Scholar
  13. 13.
    Goske MJ, Applegate KE, Boylan J et al (2008) The ‘Image Gently’ campaign: increasing CT radiation dose awareness through a national education and awareness program. Pediatr Radiol 38:265–269PubMedCrossRefGoogle Scholar
  14. 14.
    Jafari ME, Daus AM (2013) Applying Image Gently SM and Image Wisely SM in nuclear medicine. Health Phys 104:S31–36PubMedCrossRefGoogle Scholar
  15. 15.
    Gaca AM, Frush DP, Hohenhaus SM et al (2007) Enhancing pediatric safety: using simulation to assess radiology resident preparedness for anaphylaxis from intravenous contrast media. Radiology 245:236–244PubMedCrossRefGoogle Scholar
  16. 16.
    Hoskins PR, Williams JR (1992) Influence of radiologist grade on fluoroscopic patient dose. Br J Radiol 65:1119–1123PubMedCrossRefGoogle Scholar
  17. 17.
    Mahesh M (2001) Fluoroscopy: patient radiation exposure issues. Radiographics 21:1033–1045PubMedCrossRefGoogle Scholar
  18. 18.
    Nasca TJ, Philibert I, Brigham T et al (2012) The next GME accreditation system–rationale and benefits. N Eng J Med 366:1051–1056CrossRefGoogle Scholar
  19. 19.
    Miller GE (1990) The assessment of clinical skills/competence/performance. Acad Med 65:S63–67PubMedCrossRefGoogle Scholar
  20. 20.
    Warm EJ, Mathis BR, Held JD et al (2014) Entrustment and mapping of observable practice activities for resident assessment. J Gen Intern Med [Epub ahead of print]. doi: 10.1007/s11606-014-2801-5
  21. 21.
    Archer BR, Wagner LK (2000) Protecting patients by training physicians in fluoroscopic radiation management. J Appl Clin Med Phys 1:32–37PubMedCrossRefGoogle Scholar
  22. 22.
    Administration USFaD (2002) 21CFR1020.32, Part 1020 - Performance standards for ionizing radiation emitting products. Code of Federal Regulations. United States Department of Health and Human Services, Silver Springs, MDGoogle Scholar
  23. 23.
    Jones AK, Pasciak AS (2011) Calculating the peak skin dose resulting from fluoroscopically guided interventions. Part I: Methods. J Appl Clin Med Phys 12:3670PubMedGoogle Scholar
  24. 24.
    Vehmas T (2003) Do radiologists’ radiation-related opinions predict their fluoroscopy doses? Br J Radiol 76:653–655PubMedCrossRefGoogle Scholar
  25. 25.
    Ward VL (2006) Patient dose reduction during voiding cystourethrography. Pediatr Radiol 36:168–172PubMedCentralPubMedCrossRefGoogle Scholar
  26. 26.
    Brateman L (1999) Radiation safety considerations for diagnostic radiology personnel. Radiographics 19:1037–1055PubMedCrossRefGoogle Scholar
  27. 27.
    Agrawalla S, Pearce R, Goodman TR (2004) How to perform the perfect voiding cystourethrogram. Pediatr Radiol 34:114–119PubMedCrossRefGoogle Scholar
  28. 28.
    Lim R, Khawaja RD, Nimkin K et al (2013) Relationship between radiologist training level and fluoroscopy time for voiding cystourethrography. AJR Am J Roentgenol 200:645–651PubMedCrossRefGoogle Scholar
  29. 29.
    Oztas E, Parlak E, Kucukay F et al (2012) The impact of endoscopic retrograde cholangiopancreatography education on radiation exposure to experienced endoscopist: ‘trainee effect’. Dig Dis Sci 57:1134–1143PubMedCrossRefGoogle Scholar
  30. 30.
    Uradomo LT, Lustberg ME, Darwin PE (2006) Effect of physician training on fluoroscopy time during ERCP. Dig Dis Sci 51:909–914PubMedCrossRefGoogle Scholar
  31. 31.
    Zhou Y, Singh N, Abdi S et al (2005) Fluoroscopy radiation safety for spine interventional pain procedures in university teaching hospitals. Pain Physician 8:49–53PubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2014

Authors and Affiliations

  • Sweta Shah
    • 1
  • Stephane L. Desouches
    • 1
    • 2
    Email author
  • Lisa H. Lowe
    • 1
    • 3
  • Nima Kasraie
    • 1
    • 3
  • Brenton Reading
    • 1
    • 3
  1. 1.Department of RadiologyUniversity of Missouri-Kansas City SOMKansas CityUSA
  2. 2.Department of RadiologySt. Luke’s HospitalKansas CityUSA
  3. 3.Department of RadiologyChildren’s Mercy Hospitals and ClinicsKansas CityUSA

Personalised recommendations