CQI for imaging services: Part II, Obstacles to success

Continuous quality improvement (CQI) as an operations philosophy is quickly gaining acceptance in the American healthcare industry. But despite successes with this type of program in Japan and certain American industries, the quality improvement process is not problem free. In fact, there will be obstacles for many who implement such a program. For example, changes in work systems frequently stimulate emotional reactions from those affected. And while fear, apprehension and resistance can be addressed by the radiology manager, lack of corporate and administrative support will limit or prevent a CQI program's success. However, radiology managers must overcome such problems to survive in today's healthcare environment.     

The orientation coach: an important player in competency-based orientation

Competency-based orientation (CBO) is mandated by JCAHO's Agenda for Change and can improve quality patient care and employee retention. JCAHO redefined its requirements for staff orientation, training and education in 1993, emphasizing the use of competency assessment systems to foster continuous improvements in organizational quality. Proper training for staff members who conduct orientation for new employees--"orientation coaches"--is critical to the success of CBO programs. Our institution designed a training workshop to establish a common knowledge base for orientation coaches. The workshop clarifies the coaches' role and responsibilities, supplies practical information for the coaches' use and promotes a consistent approach to competency assessment. Coaches are familiarized with transitions or adjustment phases new employees typically experience and with adult learning principles, teaching behaviors and learning style differences. The orientation coaches' workshop has met organizational expectations by preparing qualified orientation leaders. New employees benefit from systematic, customized orientation plans facilitated by coaches who are comfortable with their roles and responsibilities, knowledgeable about adult education principles and competency assessment.     

The planning of orthopaedic reconstructive surgery using computer-aided simulation and design

Three-dimensional reconstructions from computed tomographic (CT) images are currently being used clinically in a wide variety of orthopaedic surgical applications. The computer may be used to select the optimum standard artificial joint replacement or to design a custom artificial joint replacement for a particular patient. Where large bony defects exist, the computer may be used to design bone allografts for joint reconstruction and to manufacture models of the bones for use in planning the surgery. In cases where osteotomies are performed to improve the mechanics of the joint, each proposed osteotomy may be simulated on the computer to identify the surgical plan that will optimally normalize the diseased joint.     

军人电子健康档案系统业务流程分析及体系架构设计

 目的 探讨军人电子健康档案系统的应用需求和体系架构.方法 参照国内外研究资料,定义基础概念,剖析系统应用需求,进而提出体系架构.结果 定义了军人电子健康档案和军人电子健康档案系统的概念,分析了军人电子健康档案系统主要应用需求和业务流程,提出了军人电子健康档案系统的体系架构.结论 本研究结果 可为"十二五"期间建设军人电子健康档案系统提供理论参考.     

An integrated visualization system for surgical planning and guidance using image fusion and an open MR

A surgical guidance and visualization system is presented, which uniquely integrates capabilities for data analysis and on-line interventional guidance into the setting of interventional MRI. Various pre-operative scans (T1- and T2-weighted MRI, MR angiography, and functional MRI (fMRI)) are fused and automatically aligned with the operating field of the interventional MR system. Both pre-surgical and intra-operative data may be segmented to generate three-dimensional surface models of key anatomical and functional structures. Models are combined in a three-dimensional scene along with reformatted slices that are driven by a tracked surgical device. Thus, pre-operative data augments interventional imaging to expedite tissue characterization and precise localization and targeting. As the surgery progresses, and anatomical changes subsequently reduce the relevance of pre-operative data, interventional data is refreshed for software navigation in true real time. The system has been applied in 45 neurosurgical cases and found to have beneficial utility for planning and guidance. J. Magn. Reson. Imaging 2001;13:967-975.     

Simple technique to visualize random set-up displacements using a commercially available radiotherapy planning system

PURPOSE: To visualize random set-up displacements in isodose distribution images, we introduce a simple technique using a commercially available radiotherapy planning system (RTP). MATERIALS AND METHODS: A distribution of set-up displacement is known to be compatible with that of a Gaussian distribution. Based on that assumption, 41 intentionally misaligned beams with 1-mm intervals were planned in the respective weights according to Gaussian distribution. "Modified" isodose distributions were then visualized using a commercially available RTP. In the next step, only two beams misaligned with one standard deviation (SD) of the Gaussian distribution were used in place of 41 beams, as a large number of beams increases the workload and is unsuitable for clinical use. Differences between the two versions of isodose distribution images were assessed visually. RESULTS: In modified dose distribution images, the edge of distribution was dull compared to normal images. These images show that the larger SD of set-up displacement dulls the edge of dose distribution. Images from two beams were not significantly different to those from 41 beams. CONCLUSION: Using this technique, the impact of random set-up displacements was effectively reflected in isodose distribution images.     

Image guidance in radiation oncology treatment planning: the role of imaging technologies on the planning process

Radiation therapy has evolved from 2-dimensional (2D) to 3-dimensional (3D) treatments and, more recently, to intensity-modulated radiation therapy and image-guided radiation therapy. Improvements in imaging have enabled improvements in targeting and treatment. As computer-processing power has improved during the past few decades, it has facilitated developments in both imaging and treatment. The historical role of imaging from 2D to image-guided radiation therapy is reviewed here. Examples of imaging technologies such as positron emission tomography and magnetic resonance imaging are provided. The role of these imaging technologies, organ motion management approaches and their potential impacts on radiation therapy are described.     

Cadaver testing to validate design criteria of an adult intraosseous infusion system

INTRODUCTION: The FAST 1 intraosseous (IO) infusion system was designed to deliver fluids and medications into the adult sternum in the prehospital and battlefield environments. OBJECTIVE: To test the prototype in 106 cadavers and excised sterna and compare it with other IO devices. RESULTS: The insertion force was similar to that of other IO devices (mean, 8.5 kg; range, 2.3-19.6 kg). In 39 of 39 trials, the depth-control mechanism inserted the portal within 1.0 mm of a predetermined distance below the anterior surface of the cortical bone. If misplaced, underpenetration was more likely than overpenetration (mean displacement, -0.3 mm; SD, 0.5 mm). After release, the portal could not be advanced further into the manubrium. Marrow was accessed in 75 of 77 trials. Mean flow rates were 109 mL/min for normal saline solution and 102 mL/min for hypertonic saline/dextran, similar to the Cook Sur-Fast device. CONCLUSION: The cadaver and bench tests demonstrated the reliability and safety of the FAST 1 system at the design/prototype stage.     

Improved dose homogeneity to the intact breast using three-dimensional treatment planning: technical considerations.

The current consensus is that breast-conservative treatment is superior to mastectomy because it provides survival equivalent to total mastectomy and axillary dissection while preserving the breast. This technique still has several technical issues that can adversely influence the successful outcome of breast-conservative treatment. Specifically, dose coverage and homogeneity must be maintained throughout the breast while reducing the hot-volume magnitude and normal tissue complications. A random retrospective three-dimensional treatment-planning study was conducted using computed tomography scans of 20 female patients with early-stage breast cancer. Two- and three-dimensional homogenous and heterogeneous treatment planning was conducted using all possible hard-wedge combinations and effective photon energies, with the goal of reducing the hot volumes in the breast below 110 percent of the prescribed dose. The hard-wedge combination that minimized the hot volumes uses either 15-degree wedges on the medial and lateral beams or a 30-degree wedge on the medial beam and a 15-degree wedge on the lateral beam. For patients with bridge distances less than 20 cm, this wedge combination reduces the hot volumes below 110 percent of the prescribed dose. For patients with bridge distances greater than 20 cm, low- and high-energy photon beams must be mixed to lower the maximum dose below 110 percent of the prescribed dose. The hot volumes in the breasts of 20 random patients was reduced below 110 percent of the prescribed dose without a significant reduction in tumor coverage.     

Assessing the impact of an orientation week on acclimation to radiology residency

PurposeAcclimating residents to radiology residency requires attention to new responsibilities, educational material, and social cohesion. To this end, we instituted a structured orientation week for incoming residents and assessed its impact.ProceduresDuring the first weeks of July 2016 and 2017, first year residents attended a five day orientation free of clinical duties, consisting of didactics, hands-on training sessions, and social events. After two orientation cohorts, residents who completed orientation week, and two cohorts who had not, were given a voluntary, anonymous survey using Likert scale questions (1 [worst] to 5 [best]) regarding preparedness for responsibilities, learning, and social cohesion. Residents were asked which components were or would have been helpful. Independent samples t-tests were performed to evaluate differences between the two groups (two-tailed p < 0.05).Findings21/37 (57%) residents participated. Higher percentages of residents who participated in the orientation week gave scores ≥4 when asked about preparedness for rotations (70% vs. 36%), learning new material (80% vs. 36%), and class cohesiveness (90% vs. 70%). Mean scores on these questions were also higher for these residents with regards to: preparedness for new responsibilities (3.7 vs. 2.9), learning new material (3.8 vs. 2.9), and class cohesiveness (4.5 vs. 3.8), with differences approaching significance (p = 0.09–0.15). Individual components receiving most votes of ≥4 were social outings, resident lunches, didactic lectures, and PACS training.ConclusionA weeklong orientation program free of clinical duties was valued by residents and contributed to acclimation to new responsibilities, education, and social cohesion.     

Improvement in tangential breast planning efficiency using a knowledge-based expert system.

A knowledge-based expert system was developed for the purpose of improving radiotherapy planning efficiency for a standardized, tangential breast technique. Treatment parameters pertaining to 150 previously planned patients were used for correlating the midplane breast contour of a new patient with an appropriate set of tangential beam weights and wedge angles; other treatment parameters including, planning target volume and isocenter, were specified by a radiation oncologist. Treatment plans generated by the expert system approach and a traditional, dosimetric approach were compared and rated prospectively in 45 patients. In addition, planning time was measured for both approaches. A performance rating of 97% was achieved for the expert system, in which an artificial neural network was used to correlate breast contours to treatment parameters, and approximately 30 minutes per patient was saved in treatment planning time. This high performance rating validated various assumptions concerning the expert system: namely, that the resultant dose distribution was not influenced by tangential field width (within the range of 7 to 12 cm), nominal beam energy (6 MV), or wedge type (physical vs. enhanced dynamic). Hence, the knowledge base may be directly transferable to other cancer centers using the same breast technique, and suggests that a global resource of radiotherapy treatment plans as well as planning strategies, categorized by treatment site, stage, and technique, may be viable.     

Advances in nuclear medicine instrumentation: considerations in the design and selection of an imaging system

Nuclear medicine remains a vibrant and dynamic medical specialty because it so adeptly marries advances in basic science research, technology, and medical practice in attempting to solve patients’ problems. As a physicist, it is my responsibility to identify or design new instrumentation and techniques, and to implement, validate, and help apply these new approaches in the practice of nuclear medicine. At Johns Hopkins, we are currently in the process of purchasing both a single-photon/coincidence tomographic imaging system and a dedicated positron emission tomography (PET) scanner. Given the exciting advances that have been made, but the conflicting opinions of manufacturers and colleagues alike regarding ”best” choices, it seemed useful to review what is new now, and what is on the horizon, to help identify all of the important considerations in the design and selection of an imaging system. It is important to note that many of the ”advances” described here are in an early stage of development, and may never make it to routine clinical practice. Further, not all of the advances are of equal importance, or have the same degree of general clinical applicability. Please also note that the references contained herein are for illustrative purposes and are not all-inclusive; no implication that those chosen are ”better” than others not mentioned is intended.     

Semi-automatic measurement of the airway dimension by computed tomography using the full-with-half-maximum method: a study of the measurement accuracy according to the orientation of an artificial airway.

OBJECTIVE: To develop an algorithm to measure the dimensions of an airway oriented obliquely on a volumetric CT, as well as assess the effect of the imaging parameters on the correct measurement of the airway dimension. MATERIALS AND METHODS: An airway phantom with 11 poly-acryl tubes of various lumen diameters and wall thicknesses was scanned using a 16-MDCT (multidetector CT) at various tilt angles (0, 30, 45, and 60 degrees ). The CT images were reconstructed at various reconstruction kernels and thicknesses. The axis of each airway was determined using the 3D thinning algorithm, with images perpendicular to the axis being reconstructed. The luminal radius and wall thickness was measured by the full-width-half-maximum method. The influence of the CT parameters (the size of the airways, obliquity on the radius and wall thickness) was assessed by comparing the actual dimension of each tube with the estimated values. RESULTS: The 3D thinning algorithm correctly determined the axis of the oblique airway in all tubes (mean error: 0.91 +/- 0.82 degrees ). A sharper reconstruction kernel, thicker image thickness and larger tilt angle of the airway axis resulted in a significant decrease of the measured wall thickness and an increase of the measured luminal radius. Use of a standard kernel and a 0.75-mm slice thickness resulted in the most accurate measurement of airway dimension, which was independent of obliquity. CONCLUSION: The airway obliquity and imaging parameters have a strong influence on the accuracy of the airway wall measurement. For the accurate measurement of airway thickness, the CT images should be reconstructed with a standard kernel and a 0.75 mm slice thickness.