Latest issue Hospital Healthcare Europe 2019

The figures given in the present document are providing the most updated comparative picture 
of the situation of healthcare and hospitals, compared to the situation in 2006

HOPE representatives provide information on the last hospital and/or healthcare reforms implemented in their countries in the last five years and on the elements on the impact of such reforms

This review aims to look at the theory behind targeted temperature management and how it is applied clinically, with attention to new research in this field and its impact on patient survival and neurological recovery

With candidates identified from different pathophysiological pathways, new technologies for measurement and more perspectives of data integration, transformation is occurring in the field of cardiac biomarkers

This article summarises the key messages from the Fourth Universal Definition of Myocardial Infarction

In an ageing and comorbid population with a high incidence of severely calcified coronary and peripheral lesions, advanced debulking techniques are frequently necessary in order to offer optimal interventional and endovascular treatment results

A research study has shown that pharmacists have a vital role in early identification and reconciliation of medications in Parkinson’s disease patients and this has the potential to prevent deterioration and prevent further morbidity in this patient profile

A good knowledge of standard ventilator waveforms allows physicians to manage patient-ventilator interaction at the bedside without the use of special technologies

Delivery of high-quality CPR is the cornerstone of all efforts to improve outcomes from sudden cardiac arrest. Debriefing is considered to be an essential component of every cardiac arrest resuscitation effort.

Few would dispute the importance of end of life care for patients and their families, but it is clear from the literature that in emergency departments, it is not always as good as it needs to be

Patient dosimetry audit is a legal requirement in the UK under the Ionising Radiation (Medical Exposure) Regulations (IRMER)¹ in order that that diagnostic reference levels (DRLs) can be established and used for X-ray imaging examinations. The principles are also applicable internationally as IRMER is itself based on European legislation and recommendations of the International Commission on Radiological Protection (ICRP). DRLs represent radiation dose levels that would be considered typical for a standard patient. They are a means of monitoring patient doses and are a guide to ‘good and normal practice’,² allowing consistently high doses to be identified and investigated. Patient dosimetry audit is the analysis of data relating to patient doses to calculate average dose indicator values (usually dose length product (DLP) for CT), check adherence to existing DRLs and set new ones where there is enough data. 
 
Patient dosimetry audit is a well established practice in diagnostic radiology. In the UK, National DRLs (NDRLs) are set by Public Health England (PHE)^3–5 and guidance on establishing Local DRLS (LDRLs) has been in place for around 15 years.² The use of electronic systems such as computed radiological information systems (CRIS) has had a profound impact on the scale and efficiency of this process.^6,7 Our local system at RRPPS (the Radiation Protection Services of University Hospitals Birmingham NHS Foundation Trust, UK) is based on CRIS downloads analysed using an in-house python software to give average dose indicators by examination and room.
 
Figure 1 demonstrates how LDRLs are used and established, and gives example data from an audit of CT lumbar spine examinations at a large UK hospital. Mean (average) doses for individual rooms can be compared against an LDRL, which is set as the mean of individual room means. In this case there is clearly a problem with scanner 4, on which the LDRL is consistently exceeded. Having identified that an issue exists via patient dosimetry audit, investigations and corrective action can be implemented. In this case the investigation revealed that whilst all of the scanners were equipped with tube-current modulation, scanner 4 had been set up with a much high reference tube current than the others. This was rectified to harmonise the protocols across all scanners. Additional cases have identified scanners with subtly different imaging protocols and tube-current modulation not being switched on! When there can easily be dozens or more protocols set up on CT scanners, it is usually impractical to check each one line-by-line and compare across every scanner, but simple setup errors will go on to influence doses for many patients. Using patient dosimetry audit to identify such issues and harmonise protocols and practices helps identify and avoid the situation of patients receiving significantly different radiation doses depending on which scanner they happen to find themselves on. In some cases, it might be justified for a particular scanner to have different protocols, and therefore give different doses to others, perhaps because it is used for different clinical conditions (for example, trauma scans). But where there is no such reason, harmonisation of protocols is a simple means of dose optimisation. 
 

 
CT is also used as standard outside of diagnostic radiology such as in nuclear medicine (with SPECT/CT and PET/CT being routine) and radiotherapy (for treatment planning scans and on-board imaging for verifying patient positioning prior to treatment). Only in the past few years has there been progress in establishing patient dosimetry audit in these areas.^8–12 In encouraging recent progress, the Institute of Physics and Engineering in Medicine (IPEM) has established working parties that undertook national audit and published data for nuclear medicine CT¹³ and radiotherapy planning CT,¹⁴ the results of which were subsequently adopted as UK NDRLs.⁵ This gives very useful data for local results to be compared against. The rest of this discussion will be on the efforts based at RRPPS to establish local systems for patient dosimetry audit in these areas, including some of the challenges we encountered and the solutions developed. In the future, it is hoped similar work will be carried out for radiotherapy on-board imaging as well. 

Cytotoxic chemotherapy is synonymous with a narrow therapeutic index, severe adverse effects for patients and occupational exposure risks for pharmacy and nursing staff

Colorectal cancer is Europe’s second biggest cancer killer, claiming the lives of nearly 200,000 people across the continent each year.

Notwithstanding the need for contingency planning, the use of automation seems to be the natural next step forward for a safer and more efficient compounding of hazardous medicines

Standardisation of doses of intravenous chemotherapy agents was initially proposed to improve pharmacy capacity and reduce medication errors and wastage; however, further optimisation of the administration of anticancer drugs can potentially contribute to a more efficient oncology unit

Dr Joaquín Casariego discusses Janssen’s solid tumour portfolio and pipeline, highlighting their commitment to improving outcomes in the solid tumour space

Best-in-class diagnostics that make a measurable difference to the management of patients with rheumatic diseases

Best-in-class portfolio, providing results you can rely on^1-24

In oncology immunotherapy, as in targeted therapy, the era of ‘one size fits all’ is past and the day-to-day work of pathologists is changing dramatically

Reducing the between-method variability in laboratory medicine is required to improve patient outcomes and traceability to global reference materials and reference methods enables manufacturers to deliver methods that give equivalent results

Auditing patient doses can and should be done, but with care to ensure that all of the contributing factors are fully considered

Patient dosimetry audit is a legal requirement in the UK under the Ionising Radiation (Medical Exposure) Regulations (IRMER)¹ in order that that diagnostic reference levels (DRLs) can be established and used for X-ray imaging examinations. The principles are also applicable internationally as IRMER is itself based on European legislation and recommendations of the International Commission on Radiological Protection (ICRP). DRLs represent radiation dose levels that would be considered typical for a standard patient. They are a means of monitoring patient doses and are a guide to ‘good and normal practice’,² allowing consistently high doses to be identified and investigated. Patient dosimetry audit is the analysis of data relating to patient doses to calculate average dose indicator values (usually dose length product (DLP) for CT), check adherence to existing DRLs and set new ones where there is enough data. 
 
Patient dosimetry audit is a well established practice in diagnostic radiology. In the UK, National DRLs (NDRLs) are set by Public Health England (PHE)^3–5 and guidance on establishing Local DRLS (LDRLs) has been in place for around 15 years.² The use of electronic systems such as computed radiological information systems (CRIS) has had a profound impact on the scale and efficiency of this process.^6,7 Our local system at RRPPS (the Radiation Protection Services of University Hospitals Birmingham NHS Foundation Trust, UK) is based on CRIS downloads analysed using an in-house python software to give average dose indicators by examination and room.
 
Figure 1 demonstrates how LDRLs are used and established, and gives example data from an audit of CT lumbar spine examinations at a large UK hospital. Mean (average) doses for individual rooms can be compared against an LDRL, which is set as the mean of individual room means. In this case there is clearly a problem with scanner 4, on which the LDRL is consistently exceeded. Having identified that an issue exists via patient dosimetry audit, investigations and corrective action can be implemented. In this case the investigation revealed that whilst all of the scanners were equipped with tube-current modulation, scanner 4 had been set up with a much high reference tube current than the others. This was rectified to harmonise the protocols across all scanners. Additional cases have identified scanners with subtly different imaging protocols and tube-current modulation not being switched on! When there can easily be dozens or more protocols set up on CT scanners, it is usually impractical to check each one line-by-line and compare across every scanner, but simple setup errors will go on to influence doses for many patients. Using patient dosimetry audit to identify such issues and harmonise protocols and practices helps identify and avoid the situation of patients receiving significantly different radiation doses depending on which scanner they happen to find themselves on. In some cases, it might be justified for a particular scanner to have different protocols, and therefore give different doses to others, perhaps because it is used for different clinical conditions (for example, trauma scans). But where there is no such reason, harmonisation of protocols is a simple means of dose optimisation. 
 

 
CT is also used as standard outside of diagnostic radiology such as in nuclear medicine (with SPECT/CT and PET/CT being routine) and radiotherapy (for treatment planning scans and on-board imaging for verifying patient positioning prior to treatment). Only in the past few years has there been progress in establishing patient dosimetry audit in these areas.^8–12 In encouraging recent progress, the Institute of Physics and Engineering in Medicine (IPEM) has established working parties that undertook national audit and published data for nuclear medicine CT¹³ and radiotherapy planning CT,¹⁴ the results of which were subsequently adopted as UK NDRLs.⁵ This gives very useful data for local results to be compared against. The rest of this discussion will be on the efforts based at RRPPS to establish local systems for patient dosimetry audit in these areas, including some of the challenges we encountered and the solutions developed. In the future, it is hoped similar work will be carried out for radiotherapy on-board imaging as well. 

Patient dosimetry audit is a legal requirement in the UK under the Ionising Radiation (Medical Exposure) Regulations (IRMER)¹ in order that that diagnostic reference levels (DRLs) can be established and used for X-ray imaging examinations. The principles are also applicable internationally as IRMER is itself based on European legislation and recommendations of the International Commission on Radiological Protection (ICRP). DRLs represent radiation dose levels that would be considered typical for a standard patient. They are a means of monitoring patient doses and are a guide to ‘good and normal practice’,² allowing consistently high doses to be identified and investigated. Patient dosimetry audit is the analysis of data relating to patient doses to calculate average dose indicator values (usually dose length product (DLP) for CT), check adherence to existing DRLs and set new ones where there is enough data. 
 
Patient dosimetry audit is a well established practice in diagnostic radiology. In the UK, National DRLs (NDRLs) are set by Public Health England (PHE)^3–5 and guidance on establishing Local DRLS (LDRLs) has been in place for around 15 years.² The use of electronic systems such as computed radiological information systems (CRIS) has had a profound impact on the scale and efficiency of this process.^6,7 Our local system at RRPPS (the Radiation Protection Services of University Hospitals Birmingham NHS Foundation Trust, UK) is based on CRIS downloads analysed using an in-house python software to give average dose indicators by examination and room.
 
Figure 1 demonstrates how LDRLs are used and established, and gives example data from an audit of CT lumbar spine examinations at a large UK hospital. Mean (average) doses for individual rooms can be compared against an LDRL, which is set as the mean of individual room means. In this case there is clearly a problem with scanner 4, on which the LDRL is consistently exceeded. Having identified that an issue exists via patient dosimetry audit, investigations and corrective action can be implemented. In this case the investigation revealed that whilst all of the scanners were equipped with tube-current modulation, scanner 4 had been set up with a much high reference tube current than the others. This was rectified to harmonise the protocols across all scanners. Additional cases have identified scanners with subtly different imaging protocols and tube-current modulation not being switched on! When there can easily be dozens or more protocols set up on CT scanners, it is usually impractical to check each one line-by-line and compare across every scanner, but simple setup errors will go on to influence doses for many patients. Using patient dosimetry audit to identify such issues and harmonise protocols and practices helps identify and avoid the situation of patients receiving significantly different radiation doses depending on which scanner they happen to find themselves on. In some cases, it might be justified for a particular scanner to have different protocols, and therefore give different doses to others, perhaps because it is used for different clinical conditions (for example, trauma scans). But where there is no such reason, harmonisation of protocols is a simple means of dose optimisation. 
 

 
CT is also used as standard outside of diagnostic radiology such as in nuclear medicine (with SPECT/CT and PET/CT being routine) and radiotherapy (for treatment planning scans and on-board imaging for verifying patient positioning prior to treatment). Only in the past few years has there been progress in establishing patient dosimetry audit in these areas.^8–12 In encouraging recent progress, the Institute of Physics and Engineering in Medicine (IPEM) has established working parties that undertook national audit and published data for nuclear medicine CT¹³ and radiotherapy planning CT,¹⁴ the results of which were subsequently adopted as UK NDRLs.⁵ This gives very useful data for local results to be compared against. The rest of this discussion will be on the efforts based at RRPPS to establish local systems for patient dosimetry audit in these areas, including some of the challenges we encountered and the solutions developed. In the future, it is hoped similar work will be carried out for radiotherapy on-board imaging as well. 

Patient dosimetry audit is a legal requirement in the UK under the Ionising Radiation (Medical Exposure) Regulations (IRMER)¹ in order that that diagnostic reference levels (DRLs) can be established and used for X-ray imaging examinations. The principles are also applicable internationally as IRMER is itself based on European legislation and recommendations of the International Commission on Radiological Protection (ICRP). DRLs represent radiation dose levels that would be considered typical for a standard patient. They are a means of monitoring patient doses and are a guide to ‘good and normal practice’,² allowing consistently high doses to be identified and investigated. Patient dosimetry audit is the analysis of data relating to patient doses to calculate average dose indicator values (usually dose length product (DLP) for CT), check adherence to existing DRLs and set new ones where there is enough data. 
 
Patient dosimetry audit is a well established practice in diagnostic radiology. In the UK, National DRLs (NDRLs) are set by Public Health England (PHE)^3–5 and guidance on establishing Local DRLS (LDRLs) has been in place for around 15 years.² The use of electronic systems such as computed radiological information systems (CRIS) has had a profound impact on the scale and efficiency of this process.^6,7 Our local system at RRPPS (the Radiation Protection Services of University Hospitals Birmingham NHS Foundation Trust, UK) is based on CRIS downloads analysed using an in-house python software to give average dose indicators by examination and room.
 
Figure 1 demonstrates how LDRLs are used and established, and gives example data from an audit of CT lumbar spine examinations at a large UK hospital. Mean (average) doses for individual rooms can be compared against an LDRL, which is set as the mean of individual room means. In this case there is clearly a problem with scanner 4, on which the LDRL is consistently exceeded. Having identified that an issue exists via patient dosimetry audit, investigations and corrective action can be implemented. In this case the investigation revealed that whilst all of the scanners were equipped with tube-current modulation, scanner 4 had been set up with a much high reference tube current than the others. This was rectified to harmonise the protocols across all scanners. Additional cases have identified scanners with subtly different imaging protocols and tube-current modulation not being switched on! When there can easily be dozens or more protocols set up on CT scanners, it is usually impractical to check each one line-by-line and compare across every scanner, but simple setup errors will go on to influence doses for many patients. Using patient dosimetry audit to identify such issues and harmonise protocols and practices helps identify and avoid the situation of patients receiving significantly different radiation doses depending on which scanner they happen to find themselves on. In some cases, it might be justified for a particular scanner to have different protocols, and therefore give different doses to others, perhaps because it is used for different clinical conditions (for example, trauma scans). But where there is no such reason, harmonisation of protocols is a simple means of dose optimisation. 
 

 
CT is also used as standard outside of diagnostic radiology such as in nuclear medicine (with SPECT/CT and PET/CT being routine) and radiotherapy (for treatment planning scans and on-board imaging for verifying patient positioning prior to treatment). Only in the past few years has there been progress in establishing patient dosimetry audit in these areas.^8–12 In encouraging recent progress, the Institute of Physics and Engineering in Medicine (IPEM) has established working parties that undertook national audit and published data for nuclear medicine CT¹³ and radiotherapy planning CT,¹⁴ the results of which were subsequently adopted as UK NDRLs.⁵ This gives very useful data for local results to be compared against. The rest of this discussion will be on the efforts based at RRPPS to establish local systems for patient dosimetry audit in these areas, including some of the challenges we encountered and the solutions developed. In the future, it is hoped similar work will be carried out for radiotherapy on-board imaging as well. 

Patient dosimetry audit is a legal requirement in the UK under the Ionising Radiation (Medical Exposure) Regulations (IRMER)¹ in order that that diagnostic reference levels (DRLs) can be established and used for X-ray imaging examinations. The principles are also applicable internationally as IRMER is itself based on European legislation and recommendations of the International Commission on Radiological Protection (ICRP). DRLs represent radiation dose levels that would be considered typical for a standard patient. They are a means of monitoring patient doses and are a guide to ‘good and normal practice’,² allowing consistently high doses to be identified and investigated. Patient dosimetry audit is the analysis of data relating to patient doses to calculate average dose indicator values (usually dose length product (DLP) for CT), check adherence to existing DRLs and set new ones where there is enough data. 
 
Patient dosimetry audit is a well established practice in diagnostic radiology. In the UK, National DRLs (NDRLs) are set by Public Health England (PHE)^3–5 and guidance on establishing Local DRLS (LDRLs) has been in place for around 15 years.² The use of electronic systems such as computed radiological information systems (CRIS) has had a profound impact on the scale and efficiency of this process.^6,7 Our local system at RRPPS (the Radiation Protection Services of University Hospitals Birmingham NHS Foundation Trust, UK) is based on CRIS downloads analysed using an in-house python software to give average dose indicators by examination and room.
 
Figure 1 demonstrates how LDRLs are used and established, and gives example data from an audit of CT lumbar spine examinations at a large UK hospital. Mean (average) doses for individual rooms can be compared against an LDRL, which is set as the mean of individual room means. In this case there is clearly a problem with scanner 4, on which the LDRL is consistently exceeded. Having identified that an issue exists via patient dosimetry audit, investigations and corrective action can be implemented. In this case the investigation revealed that whilst all of the scanners were equipped with tube-current modulation, scanner 4 had been set up with a much high reference tube current than the others. This was rectified to harmonise the protocols across all scanners. Additional cases have identified scanners with subtly different imaging protocols and tube-current modulation not being switched on! When there can easily be dozens or more protocols set up on CT scanners, it is usually impractical to check each one line-by-line and compare across every scanner, but simple setup errors will go on to influence doses for many patients. Using patient dosimetry audit to identify such issues and harmonise protocols and practices helps identify and avoid the situation of patients receiving significantly different radiation doses depending on which scanner they happen to find themselves on. In some cases, it might be justified for a particular scanner to have different protocols, and therefore give different doses to others, perhaps because it is used for different clinical conditions (for example, trauma scans). But where there is no such reason, harmonisation of protocols is a simple means of dose optimisation. 
 

 
CT is also used as standard outside of diagnostic radiology such as in nuclear medicine (with SPECT/CT and PET/CT being routine) and radiotherapy (for treatment planning scans and on-board imaging for verifying patient positioning prior to treatment). Only in the past few years has there been progress in establishing patient dosimetry audit in these areas.^8–12 In encouraging recent progress, the Institute of Physics and Engineering in Medicine (IPEM) has established working parties that undertook national audit and published data for nuclear medicine CT¹³ and radiotherapy planning CT,¹⁴ the results of which were subsequently adopted as UK NDRLs.⁵ This gives very useful data for local results to be compared against. The rest of this discussion will be on the efforts based at RRPPS to establish local systems for patient dosimetry audit in these areas, including some of the challenges we encountered and the solutions developed. In the future, it is hoped similar work will be carried out for radiotherapy on-board imaging as well. 

Patient dosimetry audit is a legal requirement in the UK under the Ionising Radiation (Medical Exposure) Regulations (IRMER)¹ in order that that diagnostic reference levels (DRLs) can be established and used for X-ray imaging examinations. The principles are also applicable internationally as IRMER is itself based on European legislation and recommendations of the International Commission on Radiological Protection (ICRP). DRLs represent radiation dose levels that would be considered typical for a standard patient. They are a means of monitoring patient doses and are a guide to ‘good and normal practice’,² allowing consistently high doses to be identified and investigated. Patient dosimetry audit is the analysis of data relating to patient doses to calculate average dose indicator values (usually dose length product (DLP) for CT), check adherence to existing DRLs and set new ones where there is enough data. 
 
Patient dosimetry audit is a well established practice in diagnostic radiology. In the UK, National DRLs (NDRLs) are set by Public Health England (PHE)^3–5 and guidance on establishing Local DRLS (LDRLs) has been in place for around 15 years.² The use of electronic systems such as computed radiological information systems (CRIS) has had a profound impact on the scale and efficiency of this process.^6,7 Our local system at RRPPS (the Radiation Protection Services of University Hospitals Birmingham NHS Foundation Trust, UK) is based on CRIS downloads analysed using an in-house python software to give average dose indicators by examination and room.
 
Figure 1 demonstrates how LDRLs are used and established, and gives example data from an audit of CT lumbar spine examinations at a large UK hospital. Mean (average) doses for individual rooms can be compared against an LDRL, which is set as the mean of individual room means. In this case there is clearly a problem with scanner 4, on which the LDRL is consistently exceeded. Having identified that an issue exists via patient dosimetry audit, investigations and corrective action can be implemented. In this case the investigation revealed that whilst all of the scanners were equipped with tube-current modulation, scanner 4 had been set up with a much high reference tube current than the others. This was rectified to harmonise the protocols across all scanners. Additional cases have identified scanners with subtly different imaging protocols and tube-current modulation not being switched on! When there can easily be dozens or more protocols set up on CT scanners, it is usually impractical to check each one line-by-line and compare across every scanner, but simple setup errors will go on to influence doses for many patients. Using patient dosimetry audit to identify such issues and harmonise protocols and practices helps identify and avoid the situation of patients receiving significantly different radiation doses depending on which scanner they happen to find themselves on. In some cases, it might be justified for a particular scanner to have different protocols, and therefore give different doses to others, perhaps because it is used for different clinical conditions (for example, trauma scans). But where there is no such reason, harmonisation of protocols is a simple means of dose optimisation. 
 

 
CT is also used as standard outside of diagnostic radiology such as in nuclear medicine (with SPECT/CT and PET/CT being routine) and radiotherapy (for treatment planning scans and on-board imaging for verifying patient positioning prior to treatment). Only in the past few years has there been progress in establishing patient dosimetry audit in these areas.^8–12 In encouraging recent progress, the Institute of Physics and Engineering in Medicine (IPEM) has established working parties that undertook national audit and published data for nuclear medicine CT¹³ and radiotherapy planning CT,¹⁴ the results of which were subsequently adopted as UK NDRLs.⁵ This gives very useful data for local results to be compared against. The rest of this discussion will be on the efforts based at RRPPS to establish local systems for patient dosimetry audit in these areas, including some of the challenges we encountered and the solutions developed. In the future, it is hoped similar work will be carried out for radiotherapy on-board imaging as well. 

Patient dosimetry audit is a legal requirement in the UK under the Ionising Radiation (Medical Exposure) Regulations (IRMER)¹ in order that that diagnostic reference levels (DRLs) can be established and used for X-ray imaging examinations. The principles are also applicable internationally as IRMER is itself based on European legislation and recommendations of the International Commission on Radiological Protection (ICRP). DRLs represent radiation dose levels that would be considered typical for a standard patient. They are a means of monitoring patient doses and are a guide to ‘good and normal practice’,² allowing consistently high doses to be identified and investigated. Patient dosimetry audit is the analysis of data relating to patient doses to calculate average dose indicator values (usually dose length product (DLP) for CT), check adherence to existing DRLs and set new ones where there is enough data. 
 
Patient dosimetry audit is a well established practice in diagnostic radiology. In the UK, National DRLs (NDRLs) are set by Public Health England (PHE)^3–5 and guidance on establishing Local DRLS (LDRLs) has been in place for around 15 years.² The use of electronic systems such as computed radiological information systems (CRIS) has had a profound impact on the scale and efficiency of this process.^6,7 Our local system at RRPPS (the Radiation Protection Services of University Hospitals Birmingham NHS Foundation Trust, UK) is based on CRIS downloads analysed using an in-house python software to give average dose indicators by examination and room.
 
Figure 1 demonstrates how LDRLs are used and established, and gives example data from an audit of CT lumbar spine examinations at a large UK hospital. Mean (average) doses for individual rooms can be compared against an LDRL, which is set as the mean of individual room means. In this case there is clearly a problem with scanner 4, on which the LDRL is consistently exceeded. Having identified that an issue exists via patient dosimetry audit, investigations and corrective action can be implemented. In this case the investigation revealed that whilst all of the scanners were equipped with tube-current modulation, scanner 4 had been set up with a much high reference tube current than the others. This was rectified to harmonise the protocols across all scanners. Additional cases have identified scanners with subtly different imaging protocols and tube-current modulation not being switched on! When there can easily be dozens or more protocols set up on CT scanners, it is usually impractical to check each one line-by-line and compare across every scanner, but simple setup errors will go on to influence doses for many patients. Using patient dosimetry audit to identify such issues and harmonise protocols and practices helps identify and avoid the situation of patients receiving significantly different radiation doses depending on which scanner they happen to find themselves on. In some cases, it might be justified for a particular scanner to have different protocols, and therefore give different doses to others, perhaps because it is used for different clinical conditions (for example, trauma scans). But where there is no such reason, harmonisation of protocols is a simple means of dose optimisation. 
 

 
CT is also used as standard outside of diagnostic radiology such as in nuclear medicine (with SPECT/CT and PET/CT being routine) and radiotherapy (for treatment planning scans and on-board imaging for verifying patient positioning prior to treatment). Only in the past few years has there been progress in establishing patient dosimetry audit in these areas.^8–12 In encouraging recent progress, the Institute of Physics and Engineering in Medicine (IPEM) has established working parties that undertook national audit and published data for nuclear medicine CT¹³ and radiotherapy planning CT,¹⁴ the results of which were subsequently adopted as UK NDRLs.⁵ This gives very useful data for local results to be compared against. The rest of this discussion will be on the efforts based at RRPPS to establish local systems for patient dosimetry audit in these areas, including some of the challenges we encountered and the solutions developed. In the future, it is hoped similar work will be carried out for radiotherapy on-board imaging as well. 

Patient dosimetry audit is a legal requirement in the UK under the Ionising Radiation (Medical Exposure) Regulations (IRMER)¹ in order that that diagnostic reference levels (DRLs) can be established and used for X-ray imaging examinations. The principles are also applicable internationally as IRMER is itself based on European legislation and recommendations of the International Commission on Radiological Protection (ICRP). DRLs represent radiation dose levels that would be considered typical for a standard patient. They are a means of monitoring patient doses and are a guide to ‘good and normal practice’,² allowing consistently high doses to be identified and investigated. Patient dosimetry audit is the analysis of data relating to patient doses to calculate average dose indicator values (usually dose length product (DLP) for CT), check adherence to existing DRLs and set new ones where there is enough data. 
 
Patient dosimetry audit is a well established practice in diagnostic radiology. In the UK, National DRLs (NDRLs) are set by Public Health England (PHE)^3–5 and guidance on establishing Local DRLS (LDRLs) has been in place for around 15 years.² The use of electronic systems such as computed radiological information systems (CRIS) has had a profound impact on the scale and efficiency of this process.^6,7 Our local system at RRPPS (the Radiation Protection Services of University Hospitals Birmingham NHS Foundation Trust, UK) is based on CRIS downloads analysed using an in-house python software to give average dose indicators by examination and room.
 
Figure 1 demonstrates how LDRLs are used and established, and gives example data from an audit of CT lumbar spine examinations at a large UK hospital. Mean (average) doses for individual rooms can be compared against an LDRL, which is set as the mean of individual room means. In this case there is clearly a problem with scanner 4, on which the LDRL is consistently exceeded. Having identified that an issue exists via patient dosimetry audit, investigations and corrective action can be implemented. In this case the investigation revealed that whilst all of the scanners were equipped with tube-current modulation, scanner 4 had been set up with a much high reference tube current than the others. This was rectified to harmonise the protocols across all scanners. Additional cases have identified scanners with subtly different imaging protocols and tube-current modulation not being switched on! When there can easily be dozens or more protocols set up on CT scanners, it is usually impractical to check each one line-by-line and compare across every scanner, but simple setup errors will go on to influence doses for many patients. Using patient dosimetry audit to identify such issues and harmonise protocols and practices helps identify and avoid the situation of patients receiving significantly different radiation doses depending on which scanner they happen to find themselves on. In some cases, it might be justified for a particular scanner to have different protocols, and therefore give different doses to others, perhaps because it is used for different clinical conditions (for example, trauma scans). But where there is no such reason, harmonisation of protocols is a simple means of dose optimisation. 
 

 
CT is also used as standard outside of diagnostic radiology such as in nuclear medicine (with SPECT/CT and PET/CT being routine) and radiotherapy (for treatment planning scans and on-board imaging for verifying patient positioning prior to treatment). Only in the past few years has there been progress in establishing patient dosimetry audit in these areas.^8–12 In encouraging recent progress, the Institute of Physics and Engineering in Medicine (IPEM) has established working parties that undertook national audit and published data for nuclear medicine CT¹³ and radiotherapy planning CT,¹⁴ the results of which were subsequently adopted as UK NDRLs.⁵ This gives very useful data for local results to be compared against. The rest of this discussion will be on the efforts based at RRPPS to establish local systems for patient dosimetry audit in these areas, including some of the challenges we encountered and the solutions developed. In the future, it is hoped similar work will be carried out for radiotherapy on-board imaging as well. 

Patient dosimetry audit is a legal requirement in the UK under the Ionising Radiation (Medical Exposure) Regulations (IRMER)¹ in order that that diagnostic reference levels (DRLs) can be established and used for X-ray imaging examinations. The principles are also applicable internationally as IRMER is itself based on European legislation and recommendations of the International Commission on Radiological Protection (ICRP). DRLs represent radiation dose levels that would be considered typical for a standard patient. They are a means of monitoring patient doses and are a guide to ‘good and normal practice’,² allowing consistently high doses to be identified and investigated. Patient dosimetry audit is the analysis of data relating to patient doses to calculate average dose indicator values (usually dose length product (DLP) for CT), check adherence to existing DRLs and set new ones where there is enough data. 
 
Patient dosimetry audit is a well established practice in diagnostic radiology. In the UK, National DRLs (NDRLs) are set by Public Health England (PHE)^3–5 and guidance on establishing Local DRLS (LDRLs) has been in place for around 15 years.² The use of electronic systems such as computed radiological information systems (CRIS) has had a profound impact on the scale and efficiency of this process.^6,7 Our local system at RRPPS (the Radiation Protection Services of University Hospitals Birmingham NHS Foundation Trust, UK) is based on CRIS downloads analysed using an in-house python software to give average dose indicators by examination and room.
 
Figure 1 demonstrates how LDRLs are used and established, and gives example data from an audit of CT lumbar spine examinations at a large UK hospital. Mean (average) doses for individual rooms can be compared against an LDRL, which is set as the mean of individual room means. In this case there is clearly a problem with scanner 4, on which the LDRL is consistently exceeded. Having identified that an issue exists via patient dosimetry audit, investigations and corrective action can be implemented. In this case the investigation revealed that whilst all of the scanners were equipped with tube-current modulation, scanner 4 had been set up with a much high reference tube current than the others. This was rectified to harmonise the protocols across all scanners. Additional cases have identified scanners with subtly different imaging protocols and tube-current modulation not being switched on! When there can easily be dozens or more protocols set up on CT scanners, it is usually impractical to check each one line-by-line and compare across every scanner, but simple setup errors will go on to influence doses for many patients. Using patient dosimetry audit to identify such issues and harmonise protocols and practices helps identify and avoid the situation of patients receiving significantly different radiation doses depending on which scanner they happen to find themselves on. In some cases, it might be justified for a particular scanner to have different protocols, and therefore give different doses to others, perhaps because it is used for different clinical conditions (for example, trauma scans). But where there is no such reason, harmonisation of protocols is a simple means of dose optimisation. 
 

 
CT is also used as standard outside of diagnostic radiology such as in nuclear medicine (with SPECT/CT and PET/CT being routine) and radiotherapy (for treatment planning scans and on-board imaging for verifying patient positioning prior to treatment). Only in the past few years has there been progress in establishing patient dosimetry audit in these areas.^8–12 In encouraging recent progress, the Institute of Physics and Engineering in Medicine (IPEM) has established working parties that undertook national audit and published data for nuclear medicine CT¹³ and radiotherapy planning CT,¹⁴ the results of which were subsequently adopted as UK NDRLs.⁵ This gives very useful data for local results to be compared against. The rest of this discussion will be on the efforts based at RRPPS to establish local systems for patient dosimetry audit in these areas, including some of the challenges we encountered and the solutions developed. In the future, it is hoped similar work will be carried out for radiotherapy on-board imaging as well. 

Patient dosimetry audit is a legal requirement in the UK under the Ionising Radiation (Medical Exposure) Regulations (IRMER)¹ in order that that diagnostic reference levels (DRLs) can be established and used for X-ray imaging examinations. The principles are also applicable internationally as IRMER is itself based on European legislation and recommendations of the International Commission on Radiological Protection (ICRP). DRLs represent radiation dose levels that would be considered typical for a standard patient. They are a means of monitoring patient doses and are a guide to ‘good and normal practice’,² allowing consistently high doses to be identified and investigated. Patient dosimetry audit is the analysis of data relating to patient doses to calculate average dose indicator values (usually dose length product (DLP) for CT), check adherence to existing DRLs and set new ones where there is enough data. 
 
Patient dosimetry audit is a well established practice in diagnostic radiology. In the UK, National DRLs (NDRLs) are set by Public Health England (PHE)^3–5 and guidance on establishing Local DRLS (LDRLs) has been in place for around 15 years.² The use of electronic systems such as computed radiological information systems (CRIS) has had a profound impact on the scale and efficiency of this process.^6,7 Our local system at RRPPS (the Radiation Protection Services of University Hospitals Birmingham NHS Foundation Trust, UK) is based on CRIS downloads analysed using an in-house python software to give average dose indicators by examination and room.
 
Figure 1 demonstrates how LDRLs are used and established, and gives example data from an audit of CT lumbar spine examinations at a large UK hospital. Mean (average) doses for individual rooms can be compared against an LDRL, which is set as the mean of individual room means. In this case there is clearly a problem with scanner 4, on which the LDRL is consistently exceeded. Having identified that an issue exists via patient dosimetry audit, investigations and corrective action can be implemented. In this case the investigation revealed that whilst all of the scanners were equipped with tube-current modulation, scanner 4 had been set up with a much high reference tube current than the others. This was rectified to harmonise the protocols across all scanners. Additional cases have identified scanners with subtly different imaging protocols and tube-current modulation not being switched on! When there can easily be dozens or more protocols set up on CT scanners, it is usually impractical to check each one line-by-line and compare across every scanner, but simple setup errors will go on to influence doses for many patients. Using patient dosimetry audit to identify such issues and harmonise protocols and practices helps identify and avoid the situation of patients receiving significantly different radiation doses depending on which scanner they happen to find themselves on. In some cases, it might be justified for a particular scanner to have different protocols, and therefore give different doses to others, perhaps because it is used for different clinical conditions (for example, trauma scans). But where there is no such reason, harmonisation of protocols is a simple means of dose optimisation. 
 

 
CT is also used as standard outside of diagnostic radiology such as in nuclear medicine (with SPECT/CT and PET/CT being routine) and radiotherapy (for treatment planning scans and on-board imaging for verifying patient positioning prior to treatment). Only in the past few years has there been progress in establishing patient dosimetry audit in these areas.^8–12 In encouraging recent progress, the Institute of Physics and Engineering in Medicine (IPEM) has established working parties that undertook national audit and published data for nuclear medicine CT¹³ and radiotherapy planning CT,¹⁴ the results of which were subsequently adopted as UK NDRLs.⁵ This gives very useful data for local results to be compared against. The rest of this discussion will be on the efforts based at RRPPS to establish local systems for patient dosimetry audit in these areas, including some of the challenges we encountered and the solutions developed. In the future, it is hoped similar work will be carried out for radiotherapy on-board imaging as well. 

Patient dosimetry audit is a legal requirement in the UK under the Ionising Radiation (Medical Exposure) Regulations (IRMER)¹ in order that that diagnostic reference levels (DRLs) can be established and used for X-ray imaging examinations. The principles are also applicable internationally as IRMER is itself based on European legislation and recommendations of the International Commission on Radiological Protection (ICRP). DRLs represent radiation dose levels that would be considered typical for a standard patient. They are a means of monitoring patient doses and are a guide to ‘good and normal practice’,² allowing consistently high doses to be identified and investigated. Patient dosimetry audit is the analysis of data relating to patient doses to calculate average dose indicator values (usually dose length product (DLP) for CT), check adherence to existing DRLs and set new ones where there is enough data. 
 
Patient dosimetry audit is a well established practice in diagnostic radiology. In the UK, National DRLs (NDRLs) are set by Public Health England (PHE)^3–5 and guidance on establishing Local DRLS (LDRLs) has been in place for around 15 years.² The use of electronic systems such as computed radiological information systems (CRIS) has had a profound impact on the scale and efficiency of this process.^6,7 Our local system at RRPPS (the Radiation Protection Services of University Hospitals Birmingham NHS Foundation Trust, UK) is based on CRIS downloads analysed using an in-house python software to give average dose indicators by examination and room.
 
Figure 1 demonstrates how LDRLs are used and established, and gives example data from an audit of CT lumbar spine examinations at a large UK hospital. Mean (average) doses for individual rooms can be compared against an LDRL, which is set as the mean of individual room means. In this case there is clearly a problem with scanner 4, on which the LDRL is consistently exceeded. Having identified that an issue exists via patient dosimetry audit, investigations and corrective action can be implemented. In this case the investigation revealed that whilst all of the scanners were equipped with tube-current modulation, scanner 4 had been set up with a much high reference tube current than the others. This was rectified to harmonise the protocols across all scanners. Additional cases have identified scanners with subtly different imaging protocols and tube-current modulation not being switched on! When there can easily be dozens or more protocols set up on CT scanners, it is usually impractical to check each one line-by-line and compare across every scanner, but simple setup errors will go on to influence doses for many patients. Using patient dosimetry audit to identify such issues and harmonise protocols and practices helps identify and avoid the situation of patients receiving significantly different radiation doses depending on which scanner they happen to find themselves on. In some cases, it might be justified for a particular scanner to have different protocols, and therefore give different doses to others, perhaps because it is used for different clinical conditions (for example, trauma scans). But where there is no such reason, harmonisation of protocols is a simple means of dose optimisation. 
 

 
CT is also used as standard outside of diagnostic radiology such as in nuclear medicine (with SPECT/CT and PET/CT being routine) and radiotherapy (for treatment planning scans and on-board imaging for verifying patient positioning prior to treatment). Only in the past few years has there been progress in establishing patient dosimetry audit in these areas.^8–12 In encouraging recent progress, the Institute of Physics and Engineering in Medicine (IPEM) has established working parties that undertook national audit and published data for nuclear medicine CT¹³ and radiotherapy planning CT,¹⁴ the results of which were subsequently adopted as UK NDRLs.⁵ This gives very useful data for local results to be compared against. The rest of this discussion will be on the efforts based at RRPPS to establish local systems for patient dosimetry audit in these areas, including some of the challenges we encountered and the solutions developed. In the future, it is hoped similar work will be carried out for radiotherapy on-board imaging as well. 

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