Implementation of Quality Systems in Nuclear Medicine: Why It Matters. An Outcome Analysis (Quality Management Audits in Nuclear Medicine Part III)

The status of nuclear medicine in China: the first official national survey

AIM/INTRODUCTION

The National Nuclear Medicine Quality Control Center of China conducted the first official survey to investigate the nationwide situation of nuclear medicine in 2020. The survey aimed to unveil the current nuclear medicine situation and its quality control in China.

MATERIALS AND METHODS

The web-based survey was conducted and the data was collected via the National Clinical Improvement System (NCIS) of China from 1st April to 31st May 2021.

RESULTS

A total of 808 institutes across 30 provinces responded to the national survey. For human resources, there are 4460 physicians, 3077 technologists, 339 physicists, and 309 radiochemists. There are 887 single-photon imaging instruments, including 823 SPECT or SPECT/CT, and 365 PET instruments including 314 PET/CT. Six hundred twenty-four institutes perform SPECT examinations and 319 institutes perform PET examinations. 60% of SPECT scans are bone scintigraphy. A total of 97% of PET scans use an [18F]F-FDG tracer. Furthermore, 587 institutes provide radionuclide therapy services but only 280 institutes have admission rooms. The top three radionuclide therapies are [131I] therapy of hyperthyroidism with 546 institutes, [89Sr] therapy of bone metastasis with 400 institutes, and [131I] therapy of differentiated thyroid cancer with 286 institutes. Finally, for the frequency of equipment quality control per year, there are about 67 times self-test within the department for SPECT instruments and 111 times for PET instruments on average in each province. There are about three failures of SPECT and five failures of PET on average per year in each province. There are 408 institutes (of 624 SPECT institutes) performing quality control of SPECT radiopharmaceuticals, 216 (of 319) for PET radiopharmaceuticals, and 373 (of 587) for radionuclide therapy.

CONCLUSION

These results of the first official survey towards current status of nuclear medicine in China are the foundation for the establishment of the quality control management system.

Assessing nuclear medicine practices: a critical evaluation of QUANUM through a quality improvement perspective and its wider relevance

Quality Management Audits in Nuclear Medicine (QUANUM) is an initiative conceived by the International Atomic Energy Agency to enhance global standards in Nuclear Medicine practices. Acknowledging the intricate regulatory frameworks and the necessity for multidisciplinary collaboration, QUANUM has gained global acceptance, demonstrating widespread implementation and positive impacts on patient care. This manuscript critically evaluates the QUANUM program through the lens of quality improvement (QI), by employing established and validated QI tools. Our analysis identifies areas of conformance, underscores key strengths inherent to QUANUM, and pinpoints further learning opportunities for continuous enhancement. Additionally, we assert that the insights derived from scrutinizing this global project within Nuclear Medicine, have valuable implications for departments aspiring for establishing good quality management systems, thereby contributing to the improvement of patient care.

The relative contribution of photons and positrons to skin dose in the handling of PET radiopharmaceuticals

BACKGROUND

Despite recommendations to use syringe and vial shields to reduce exposure of the hands of staff when manipulating PET radiopharmaceuticals, operators sometimes prefer to work without shields, believing that the faster handling limits the equivalent dose. The aim of this work is to show that this approach does not properly consider the contribution of positrons to the dose.

MATERIALS AND METHODS

Using the Varskin+ code, skin doses were calculated for syringes of various sizes, filled with ¹⁸F, ¹¹C or ⁶⁸Ga solution. Syringes without shielding, or shielded with 2 mm and 10 mm of tungsten were considered.

RESULTS

Dose rate values in mSv/s per MBq, averaged on a 1 cm² surface at a depth of 0.07 mm were calculated for all the above conditions. For example, in the case of 3 mL ¹⁸F syringe at 1 mm from the skin, the dose rate without shielding is 1.32E-02 and 8.63E-04 for positrons and photons respectively. For ¹¹C, the corresponding dose rates are 4.70E-02 and 8.90E-04 respectively, and for ⁶⁸Ga, 8.52E-02 and 9.48E-04.

CONCLUSIONS

Our results show that the dose due to positrons is the principal component of skin irradiation, by a factor of 3-100, depending on the conditions. The use of shields for syringes and vials is necessary to avoid unjustified skin exposures, that may challenge dose limits. In our opinion, automatic systems for dispensing and allowing injection with shielded syringes, or automatic injectors, are economically justified and should be adopted in PET.

Development and Implementation of a Professional Practices Evaluation during Radiopharmaceuticals Administration

Securing both the patient and radiopharmaceuticals (RPs) circuit is an essential concern in nuclear medicine (NM). These circuits converge at the RP administration phase, a key step in patient management in NM. In a continuous quality improvement approach, we developed and implemented an evaluation of professional practices (EPPs) methodology focused on RPs injection to identify and correct deviations from good practices. The nuclear medicine technologists (NMTs) of a single center were evaluated. A specific audit grid was designed for this purpose, covering 4 main themes. Following the audit campaign, an improvement action plan was set up to address the non-conformities observed. Nine NMTs were audited on 4 RPs injections each. The mean total score was 93.36% with, on average, 7.01% and 3.00% of unmet and partially met criteria, respectively. In view of the non-compliance rates of hygiene and radiation protection items, theoretical reviews of these themes were included in the improvement action plan. As a part of the quality assurance system of a healthcare unit, EPPs are useful for identifying and correcting practice deviations at an early stage. They should be regularly repeated and combined with rigorous training and qualification of operators involved in RPs injection.

Medical imaging and nuclear medicine: a Lancet Oncology Commission

The diagnosis and treatment of patients with cancer requires access to imaging to ensure accurate management decisions and optimal outcomes. Our global assessment of imaging and nuclear medicine resources identified substantial shortages in equipment and workforce, particularly in low-income and middle-income countries (LMICs). A microsimulation model of 11 cancers showed that the scale-up of imaging would avert 3·2% (2·46 million) of all 76·0 million deaths caused by the modelled cancers worldwide between 2020 and 2030, saving 54·92 million life-years. A comprehensive scale-up of imaging, treatment, and care quality would avert 9·55 million (12·5%) of all cancer deaths caused by the modelled cancers worldwide, saving 232·30 million life-years. Scale-up of imaging would cost US$6·84 billion in 2020-30 but yield lifetime productivity gains of $1·23 trillion worldwide, a net return of $179·19 per $1 invested. Combining the scale-up of imaging, treatment, and quality of care would provide a net benefit of $2·66 trillion and a net return of $12·43 per $1 invested. With the use of a conservative approach regarding human capital, the scale-up of imaging alone would provide a net benefit of $209·46 billion and net return of $31·61 per $1 invested. With comprehensive scale-up, the worldwide net benefit using the human capital approach is $340·42 billion and the return per dollar invested is $2·46. These improved health and economic outcomes hold true across all geographical regions. We propose actions and investments that would enhance access to imaging equipment, workforce capacity, digital technology, radiopharmaceuticals, and research and training programmes in LMICs, to produce massive health and economic benefits and reduce the burden of cancer globally.

Q-Bot: automatic DICOM metadata monitoring for the next level of quality management in nuclear medicine

BACKGROUND

Regular and precise inspection of the realization of the local nuclear medicine standard operation procedures (SOPs) is very complex and time-consuming, especially when large amount of patient data is obtained from a wide scale of different scan procedures on a daily basis. DICOM metadata comprise a complete set of data related to the patient and the imaging procedure, and consequently all information necessary to evaluate the compliance with the actual SOP.

METHODS

Q-Bot, an automatic DICOM metadata monitoring tool which is capable to verify SOP conformities, was tested for 11 months at two nuclear medicine departments. Relevant parameters, such as patient ID, patient mass and height, injected activity, and uptake time, were investigated in the case of adult ¹⁸F-FDG whole-body PET/CT and ^99mTc-MDP gamma camera bone scans on a daily basis. Q-Bot automatically inspected the actual SOP compliance of these relevant DICOM parameters. Q-Bot graphical user interface (GUI) provided a summary of the outliers in a table format to be investigated by a dedicated technologist. In addition, information related to the error handling was also collected for retrospective analysis of long-term tendencies.

RESULTS

In total, 6702 PET/CT and 2502 gamma camera scans were inspected, from which 8581 were confirmed as valid patient study without errors. Discrepancies related to the lack of a parameter, not appropriate format, or improper scan procedures were found in 623 cases, and 156 out of these were corrected before the medical reading and reporting. SOP non-conformities explored with Q-Bot were found to be non-correctable in 467 cases. Systematic errors to our practice turned out to be the manual radiopharmaceutical injection, the allowance to use both SI and non-SI units, and the clear definition of decimal point symbol to use.

CONCLUSION

The daily evaluation of Q-Bot results provided early detection of errors and consequently ensured the minimization of error propagation. Integration of a QM software that inspects protocol compliance at a nuclear medicine department provides significant support to detect non-conformities for technologists, and much higher confidence in image quality for physicians.

[Quality guidelines for radiopharmacy: Development of a risk-assessment tool]

OBJECTIVES

The medical management of patients, which involves securing the drug circuit, is a major public health objective. As part of quality management, a number of risk assessment and risk management tools in care units are validated and available. However, medication management in radiopharmacy departments represents a complex and specific process. The aim of the "Quality guidelines for radiopharmacy" working group of the French society of radiopharmacy (SoFRa) was to develop a risk-assessment tool that is a priori adapted to radiopharmacy activity.

METHODS

A qualitative risk matrix was developed, based on available analysis tools and current regulations concerning radiopharmacy practice. The tool was then programmed to obtain a summary and scoring for each risk category, as well as a quantitative analysis of the risks identified in radiopharmacy.

RESULTS

Our tool contains 262 issues. The qualitative study integrates the risks related to the circuit of radiopharmaceuticals, but also risks related to personnel. The quantitative study makes it possible to carry out an automated analysis of the actions to carry out in priority to improve the practices.

CONCLUSIONS

This work led to the development of a self-assessment tool for the a priori analysis of risks that are adapted to the practice of radiopharmacy. It allows easy analysis of the entire circuit of radiopharmaceuticals from a single tool and meet the expectations of health authorities. This common and validated tool is available to the pharmaceutical community.