This article provides suggestions for identifying factors that may lead to a performance gap in achieving appropriate radiation dose for patients receiving low-dose lung cancer screening. This activity corresponds to the PLAN section of the PDSA Worksheet. Interventions are suggested for addressing these factors and demonstrating improved performance that you will record in the DO section of the PDSA Worksheet.
A first step in getting started is to establish a team that includes at least one radiologist, CT technologist, and a medical physicist with CT experience. Consider using some of the tools for characterizing performance factors in the Set a Goal and Analyze Baseline Data section of the Performance Improvement Resources Knowledge Base article.
Planning Activities and Suggested Interventions
Planning Activity: Investigate at which facilities the performance issue is occurring if you have more than one facility under your Corporate Account. Review the Achieving Appropriate Radiation Dose - Data Review article for how to review your LCSR performance reports.
Planning Activity: Investigate if the issue is occurring on all CT scanners.
Intervention Suggestion: Once one or more scanners in a center are identified, please follow the following activities.
Planning Activity: Investigate if there is any variation among your CT technologists performing the exams.
Intervention Suggestion: Consider educating your CT technologists on why low-dose protocols are important for lung cancer screening, which is different than CT scans performed for known lung cancer diagnosis, staging, and treatment evaluation.
Planning Activity: Investigate variations in how you prescribe protocol exams for individual patients, whether this is done by radiologists, CT technologists, or other individuals as defined by how your practice operates.
Intervention Suggestion: Base scanning protocols on BMI and optimize protocols in the overweight and obese population . Involve both internal medical physicists and radiologists in the team that standardizes these protocols .
Planning Activity: Review your CT technology and options to optimize radiation exposure .
Optimize radiation reduction technology for the scanner – the CT equipment manufacturer can help with using radiation reduction technology for their scanner.
Choose automatic parameters – automatic exposure control (AEC) and/or automatic kV selection. Each manufacturer may have recommendations unique to their systems and system features. Be sure to work with your CT equipment manufacturer and a qualified medical physicist to ensure the safe and appropriate operation of AEC systems.
Use a manual technique chart that prescribes different tube current and/or kV values as a function of patient size.
Planning Activity: Investigate if your lung cancer screening CT protocols align with national recommendations such as the ACR Lung Cancer Screening Practice Parameters and AAPM Sample Protocols for the make and model of CT scanners in your practice [3, 4].
Adjust radiation exposure lower for smaller patients and higher for larger patients as is necessary to obtain appropriate image quality.
Correct protocol builds on your CT scanner and train CT technologists on which ones to use.
Planning Activity: Review if your protocol naming conventions are clear.
Intervention Suggestion: Label “lung cancer screening” and “lung cancer” as two different protocol names so as not to be confusing. Consider “lung screening” and “lung cancer.”
Planning Activity: Review if the orders for CT lung cancer screening are different than for other chest CTs.
Intervention Suggestion: Update orders so that selection of the correct protocol using low-dose CT is clear when a screening exam is what is intended by the ordering provider.
Consider revisiting your data in 1-3 months depending on the factor(s) identified and the volume of exams performed to have enough data points for review.
Peng R, Mardakhaev E, Shmukler A, et al. Meeting ACR dose guidelines for CT lung cancer screening in an overweight and obese population. Acad Radiol. 2021;28(3):381-386. doi: 10.1016/j.acra.2020.02.009
Demb J, Chu P, Yu S, et al. Analysis of computed tomography radiation doses used for lung cancer screening scans. JAMA Intern Med. 2019;179(12):1650-1657. doi: 10.1001/jamainternmed.2019.3893
Kazerooni EA, Austin JHM, Black WC, et al. ACR–STR practice parameter for the performance and reporting of lung cancer screening thoracic computed tomography (CT). Available at: https://www.acr.org/-/media/ACR/Files/Practice-Parameters/CT-LungCaScr.pdf. American College of Radiology. Updated 2019. Accessed October 25, 2022.
American Association of Physicists in Medicine. Lung cancer screening CT protocols version 5.1. Available at: https://www.aapm.org/pubs/ctprotocols/documents/lungcancerscreeningct.pdf. American Association of Physicists in Medicine. Updated 2015. Accessed October 25, 2022.