Watching out for the youngest patients

As part of a broader patient-safety movement, hospitals and physicians increasingly are focusing on ways to reduce treatment risks for pediatric patients. One particular area of concern is the use of radiation-intensive CT scans in children.

Three physician specialty groups have made recommendations to avoid the use of CT scans in children for certain conditions. Those recommendations are part of the medical profession's Choosing Wisely campaign, which has sought to reduce the use of imaging and exposure to radiation and encourage use of alternative imaging methods.

In addition, the ECRI Institute, a Plymouth Meeting, Pa.-based not-for-profit organization that researches patient-safety and technology issues, cited CT radiation exposure in pediatric patients as one of its top 10 health technology hazards for 2014. The annual list aims to make hospitals aware of safety issues associated with the use of certain technologies.

Other areas of concern for pediatric patient safety are electronic health records and use of adult-sized equipment for smaller pediatric patients.

Children generally are more sensitive than adults to the effects of ionizing radiation. Pediatric patients with chronic diseases who undergo multiple CT scans as part of their treatment regimen may be at risk for cancers later in life. A recent study estimated that the 4 million CT scans performed on children each year could result in 5,000 future cancer diagnoses.

Some experts say that even with the increased awareness among providers of the risk of CT scans, there has been little change in clinical practices at hospitals. Utilization of imaging has declined over the past five years or so, but questions remain about whether hospitals are optimizing radiation dose when patients do undergo CT scans.

“Awareness itself doesn't translate into improvement in practice,” said Dr. Rebecca Smith-Bindman, director of the Radiology Outcomes Research Lab at the University of California, San Francisco. “Variation remains a considerable problem.”

This was one reason why the ECRI Institute placed CT radiation exposure in pediatric patients on its top 10 technology hazards list. Two of the 10 hazards on ECRI's list relate to medical technologies used to treat children. The institute also cited risks to pediatric patients from adult technologies, which could include electronic health records that have not been configured to support pediatric-specific data, as well as use of adult medical devices when a smaller, child-sized model is not available.

“We've seen growing momentum being built up toward more care being taken with pediatric care and technology safety,” said Jim Keller, ECRI's vice president of health technology evaluation and safety. “Awareness is key. Building in systems to make sure the awareness gets put into practice is really important.”

Radiologists for several years have focused on reducing radiation doses and inappropriate utilization at a time when CT utilization rates have leveled off. While CT utilization in children 5 to 14 years old nearly tripled at six health systems from 1996 to 2005, usage rates declined from 2008 to 2010.

Two fairly recent efforts—the Alliance for Radiation Safety in Pediatric Imaging's Image Gently initiative and the Choosing Wisely campaign—have raised awareness about the risks of radiation exposure in both children and adults.

Clinicians are being more cautious about ordering inappropriate CT scans, but many patients continue to receive CT scans even when alternative modalities with lower radiation exposure such as MRI or ultrasound are available. CT scans generally deliver the highest doses of radiation.

Boston Children's Hospital uses MRI as the primary imaging modality for patients with Crohn's disease and those with suspected ventriculo-peritoneal shunt malfunctions. It previously used CT scans for those conditions. “We're really almost a mirror image of how we imaged 10 years ago,” said Dr. Michael Callahan, director of computed tomography at the 395-bed children's hospital.

Another concern ECRI raised is that few providers share information about previous CT and imaging studies, which can lead to duplicate scans, higher costs and increased patient exposure to radiation. This is likely to become less of a problem, however, as more health systems and hospitals begin to use image-sharing networks that are part of health information exchanges. They also are using picture archiving communications systems known as PACS that allow providers to share images across hospitals and regions.

“It all boils down to having a good understanding of the history for that child, especially if they are coming from a different healthcare institution,” Keller said.

ECRI recommends that hospitals implement checklists or protocols that notify providers when alternative imaging methods should be used or if previous scans are available. UCSF's Smith-Bindman said, however, that many hospitals have not implemented programs that assess usage and seek to standardize imaging. In addition, few hospitals collect data about CT utilization and dosage that can be used to identify outliers and generate benchmarks.

UCSF started a project two years ago to gather data on adult and pediatric patients who have undergone CT scans at the system's hospitals. The data looked at the average doses for specific areas of the body—head, chest and stomach—and also identified outliers. Assessing the data and implementing standardized doses led to a 40% drop in radiation for patients.

“You can really have an impact,” Smith-Bindman said.

Keller and other experts say children's hospitals are more likely to be leaders in reducing CT radiation exposure in pediatric patients and ensuring that the right supplies and medical devices are being used in the treatment of children. Six children's hospitals—Boston Children's, Children's Hospital of Philadelphia, Cincinnati Children's Hospital Medical Center, Duke University Medical Center in Durham, N.C., Massachusetts General Hospital, Boston, and Primary Children's Hospital in Salt Lake City—have formed a coalition to develop best practices for optimal CT scans and a dose index based on the size of the patient and common medical indications, such as appendicitis.

“We want to lower doses in studies that are performed frequently,” Callahan said.

In hospitals that treat adult and pediatric patients, there may be less attention to the specific needs of children, these experts say.

“Pediatric hospitals have the advantage of focusing solely on the pediatric patients,” Keller said. Hospitals that treat adults and children “have such a broad population (that) the pediatric needs can slip through the cracks.”

The fast-moving adoption of electronic health records also may present challenges specific to pediatric patients. The Agency for Healthcare Research and Quality this year provided a format for EHR developers to understand what information should be included about children in a health record. In some cases, EHRs do not include information about vaccinations or allow height and weight to be viewed on the same screen.

“Until now many EHRs have lacked child-specific functionality such as the ability to record age-appropriate development, nutrition, immunizations or growth,” Dr. Thomas McInerny, president of the American Academy of Pediatrics, said in a written statement this year.

Dr. Davidson Freeman, a pediatrician at Georgia Regents Health System in Augusta, Ga., said his health system's EHR has been configured to include pediatric options. But some community physicians who are using a different EHR system have had some problems with their own systems, which he described as not “pediatric friendly.”

ECRI also cited the use of adult doses for CT and X-ray and medication dosing errors as other examples of adult technologies that can be a risk to pediatric patients. The institute recommended that clinicians weigh only infants and children in kilograms to further prevent medication dosing errors, use e-prescribing systems that have pediatric-specific medication libraries and consider whether an EHR complies with the AHRQ's format when making an EHR purchasing decision.

“A continuing trend is definitely tied into the growth of IT-based medical devices and adoption of EHRs in the hospitals,” Keller said. “The rapid adoption of EHRs is a good thing but raises new safety concerns.”

The 2013 ECRI hazards list also focused on how using adult technologies on pediatric patients can impact their care. It noted there are few devices developed to specifically target children, so adult technologies are often the only alternative.

Keller said hospitals should make sure to consider the needs of their pediatric patients when procuring medical devices and supplies as well as acknowledge that the care of pediatric patients often is intermingled with adult patients who are treated in the same care settings.

“Pediatric-specific devices can be slow to reach the market because the small number of patients available to study, the devices' high-risk nature and high development costs,” ECRI said in the report. “Thus healthcare providers are often put into the position to use a technology designed for adults to diagnose or treat conditions in children.”

Matthew Maltese, director of biomechanics research at the Children's Hospital of Philadelphia, and six other research groups in September received $3.5 million in grants aimed at boosting the development and availability of pediatric medical devices. The grants are the third round of funding that the FDA has awarded to support the development of pediatric devices since 2009.

At the Children's Hospital of Philadelphia, Maltese and other engineers work with clinicians to translate ideas into marketable devices. The grant is expected to support that work, which started Oct. 1.

“There is an unmet need,” Maltese said. “The challenge is that there are barriers to pediatric device development.”

Follow Jaimy Lee on Twitter: @MHjlee