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Original Article
Radiographers’ Conception and Perspectives Regarding Optimization of the Quality of the Image in Pediatric Digital
Radiography
Haney A Alsleem1, Hussain M Almohiy2
1Departments of Radiological Science, Colleges of Applied Medical Sciences, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia. 2Departments of Radiological Science, Colleges of Applied Medical Sciences King Khalid University, Abha, Saudi Arabia.
*Correspondent author: [email protected]
Abstract
Background: With the introduction of advance digital radiography (DR) systems, the radiation doses patients are exposed to can be significantly minimized while maintaining optimal image quality. However, if radiographers do not adjust their DR practices, patients could be exposed to greater doses. Given the higher radio-sensitivity of children, the motive of the study was to appraise radiographers’ conception and perspectives regarding optimization of the quality of the image in the field of pediatric DR.
Participants and Methods: A quantitative survey was designed and used to appraise the knowledge, awareness, and perspectives of radiographers from four pediatric hospitals in Saudi Arabia about DR. T-tests and Chi-squared analysis were used to find out the differences between participants within each department and between hospitals.
P-values diminished than 0.05 were regarded as statistically significant.
Results: Most of the participants (76%) had not acquired any proper training in pediatric DR. Also, half of all respondents were unaware about the radiation doses administered in their departments.
Conclusions: The results demonstrated that the greater number of participants did not have appropriate levels of knowledge or experience in the field of pediatric DR. Most participants had not considered the importance of strict collimation when utilizing the image-crop function within a software program, thus it emphasizes the need for more training to improve their practices and performance when using DR systems.
Key words: Radiographers, Digital radiography, Dose creep, Digital radiography.
Citation: Alsleem HA, Almohiy HM. Radiographers’ conception and perspectives regarding optimization of the quality of the image in pediatric digital radiography.
JUMJ, September 1, 2018; 5(3): 15 - 24.
Introduction
Digital radiography (DR) is a relatively new technology in medical imaging that has revolutionized the practice of imaging modalities in medicine. The shift from analogue screen and film radiography (SFR) towards DR has improved the clinically related yield, quality of image optimization, and different diagnosis- related clarification(1). The introduction of DR has played an important role in reducing radiation doses(2-4). While the use of DR has many advantages, there are potential drawbacks. The exposure factors
and optimization methods used in DR and SFR are not the same (1). DR may put patients to more dose of ionising radiation than is appropriate for recommended quality of image if radiographers do not adjust and improve their practices(2-4). Dose or exposure creep has been shown to exist in DR and may result due to the wide dynamic ranges of DR systems(5-8). DR technologies have different imaging processes and therefore different guidelines for image quality optimization
(2, 3)
. Radiographers, without the adequate knowledge or experience, could
. potentially expose patients to radiation
doses higher than those necessary for the required radiographs(3, 9).
Given the potential drawbacks of DR use, radiographers should receive more education so that they may effectively maximize the advantages of DR(1, 10, 11). Radiographers are responsible for achieving the highest possible improvement in the quality of the image at the lowest radiation dose, which is humanly possible(11). Radiographers are not entirely aware about the difference between digital cropping and physical collimation(18). Even though the majority that agreed that an important aspect is collimating of the beam of X-ray (in DR), 74.5% of them did not modify the beam collimation but relied on cropping via post-processing methods(18). A significant number of radiographers hailing from both Saudi Arabia and Australia had not acquired precise tutelage in the imaging modalities of pediatrics concerning DR despite agreeing that pediatric imaging is different, challenging and sensitive to radiation compared to adult DR(18). Pediatric patients are more susceptible to radiation(12), and the appropriate exposure factors should be selected to produce optimum image quality(13, 14). The X-ray tube potential (kVp), exposure time (s), tube current (mA), focal-spot size, source- to-image distance, and other parameters should be chosen with caution. More attention to detail is needed, and specific precautions must be taken in the radiography of pediatric patients(15-17). This research aspires to evaluate radiographers’ conception and perspectives regarding quality of image optimization in pediatric DR and radiation dose management in chosen hospitals in Saudi Arabia. The results could improve the performance of radiographers and therefore improve quality of image while sustaining decreased radiation exposure to patients.
Participants and Methods Ethics and Questionnaire Design
Radiographers’ conception and perspectives regarding pediatric DR were evaluated and juxtaposed using a quantitative survey. The required ethical
approvals were obtained from the University’s review board and each participating hospital before conducting the study. The approval number of the ethics committee for King Fahad Medical City, Kingdom of Saudi Arabia is FWA00018774. Unfortunately, the nationality of radiographers was not considered in the study. The gender was ignored from the study because most of the female participants did not respond to the question.
A questionnaire containing four sections was used. The first sections focused on the radiographers’ demographic information, including their years of radiographic experience, their experience using DR, and their education qualification. One section assessed their knowledge and attitude regarding as perfect and effective as possible of the dose of radiation and quality of the image in DR. The last section inquired about their knowledge and attitude regarding the special considerations required in pediatric DR. The survey questionnaire used questions which were closed-ended;
however, a little amount of questions which were open-ended were also included to allow response from more participants. To assess radiographers’
perception of DR, they were asked to grade their settlement with many statements from 1 (strongly contrast) to 5 (strongly give consent).
Mode of recruitment and collection of data
Radiology departments in public hospitals in Saudi Arabia that included pediatric radiography (n = 4) were contacted. After the objectives of the study were explained, the researchers obtained permission to conduct the study from the heads of each of the four radiology departments. The survey was then provided to all radiographers who worked with pediatric patients in each of the four hospitals. The survey was conducted simultaneously in the four hospitals. The availability and accessibility of these hospitals to the investigators were the major determinants for choosing them.
Hospitals were coded as King Fahad Hospital in Hofuf (HA), Alhasa, King Fahad University Hospital (HB),
. Alkhobar, King Fahad Specialist Hospital
(HC), Dammam and Maternity and children Hospital MCH, Dammam.
In April 2015, packages containing a hard copy of the survey, a call to partake in the assessment, a statement in forthright dialect, and the required questionnaires were sent to the chairman of the department of radiology at each of the four hospitals. The persons who took part in the survey were asked to return the completed form of the questionnaire in an envelope directly to the researchers to ensure confidentiality.
Data analysis
Saudi Arabian radiographers’ conception and perspectives regarding pediatric DR and their demographic information were compared using SPSS Statistics with 18th version (SPSS Inc., of Chicago, country- USA). Chi-square test was performed to find out any significant dissonances between the responses of the radiographers among hospitals.
Dissonances were considered noteworthy if the P-value was <0.05, based on two- sided Chi square test.
Results
Participants’ demographic characteristics The study included responses from 78 radiographers working in four different hospitals in Saudi Arabia with a response rate of ~82%. Demographic information and the professional experience of the participants are illustrated in Table 1.
The knowledge and attitudes of the participants regarding quality of image optimization and quantity management were compared. Most of them also stated that there is a system in place to find out the percentage of examinations and whether they can be considered under the acceptable exposure range.
Most of the respondents from different hospitals reported that they considered certain conceptions and practices, including monitoring the exposure indicators, using appropriate image processing techniques, and managing artefacts and noise, to optimize image quality.
Most of the participants had lack of experience in CR (mostly less than 50%),
with the exception of HB (10-15 years’
experience was 64.3%). Also, experience in DDR and/or IDR was lacking in most hospitals (less than 50%). The only exception of that being HB (64.3%).
Most of the participants from the four hospitals had received formal training in DR (>56%). However, the participants from HD and HB (44% and 37.5%, respectively) had not received any proper tutelage in any type of DR. Remarkably, none of the persons who took part from HA had received any proper tutelage in radiation safety practices for DR. Results showed that 65.6% of the people who took part from HD had not received any DR instructions (Table 1).
Regarding receiving any tutelage in radiation safety practices in DR (Table 1), HA and HD had negligible positive responses (Nil and 34.4% only), while HB (79.2%) and HC (57.1%) had some acceptable positive responses (p <0.001).
Majority of participants from all four hospitals reported that there are acceptable established exposure values in their institution/department. 51.3 % of all the participants who responded were unconcerned about the radiation doses administered in their departments.
However, majority of respondents from HB and HC (81.8% and 100%, respectively) were concerned. Majority of participants from HB, HC, and HD (Table 1) reported that they were familiar and aware of the "As Low as Reasonably Achievable Principle" (91.3%, 100%, and 66.7%, respectively) with the exception being HA (18.2%).
Most participants (66%) reported that they had not acquired any proper tutelage in pediatric DR (Figure 1). None of the people who participated in the study from HC had received any proper tutelage in pediatric DR.
Knowledge and attitudes regarding pediatric imaging
All participants agreed that pediatric radiography involves challenges in imaging that differ from those of typical radiography in adults. All participants from HA, HB, HC and HD reported “DR has increased dynamic range” as an advantage of DR. The majority of
. participants (61.8%) reported that
pediatric patients are twice as sensitive to ionizing radiation as adults (Table 2).
More than half of the participants (52.6%) agreed that patients of pediatric age are 10 times more sensitive to ionizing radiation in comparison to adults. It can be seen from Table 2 that almost two-thirds
(65.2%) were of the opinion that for patients below the age of 15 years, acute radiation exposure is associated with more than double the normal risk of cancer mortality than for patients in other age groups. Table 2 also illustrates other perceived concept reported by participants regarding pediatric radiography.
Table 1: Participants’ demographics, work and training characteristics of the investigated radiographers (total number = 78). Data shown are frequency; n and (%), and, p values.
Variable
Hospital HA HB HC HD Total P-value
Age groups
<25 years 2 (15.4) 0 (0.0) 0 (0.0) 2 (9.1) 4 (6.2)
<0.001 25 – 35 years 8 (61.5) 4 (17.4) 2 (28.6) 20 (90.9) 34 (50)
36 – 45 years 3 (23.1) 1 (4.3) 4 (57.1) 0 (0.0) 8 (11.8) 46 – 55 years 0 (0.0) 8 (34.8) 0 (0.0) 0 (0.0) 8 (11.8)
>55 years 0 (0.0) 10 (43.5) 1 (14.3) 0 (0.0) 11 (16.2)
Highest qualification
Diploma 4 (30.8) 1 (4.2) 2 (22.2) 13 (40.6) 20 (29.4) 0.011 Bachelor 4 (30.8) 16 (66.7) 3 (33.3) 5 (15.6) 28 (41.2) Master 5 (38.5) 7 (29.2) 4 (44.4) 13 (40.6) 29 (42.6) PhD 0 (0.0) 0 (0.0) 0 (0.0) 1 (3.1) 1 (1.5)
Experience in CR
<5 years 3 (25.0) 0 (0.0) 0 (0.0) 3 (10.3) 6 (8.1) 0.009 5-10 years 4 (33.3) 1 (7.1) 2 (28.6) 9 (31) 16 (21.6) 10-15 years 4 (33.3) 9 (64.3) 1 (14.3) 7 (24.1) 21 (28.4)
>15 years 1 (8.3) 4 (28.6) 4 (28.6) 5 (17.2) 14 (18.9) None 0 (0.0) 0 (0.0) 0 (0.0) 5 (17.2) 5 (6.8)
Experience in DDRor IDR?
<5 years 2 (15.4) 0 (0.0) 0 (0.0) 3 (10.7) 5 (8.1) 0.069 5-10 years 6 (46.2) 2 (14.3) 3 (33.3) 7 (25) 18 (29) 10-15 years 2 (15.4) 9 (64.3) 3 (33.3) 7 (25) 21 (33.9)
>15 years 2 (15.4) 3 (21.4) 1 (14.3) 5 (17.9) 11 (17.7) None 1 (7.7) 0 (0.0) 0 (0.0) 6 (21.4) 7 (11.3) Receiving formal training
in any type of DR?
Yes 9 (69.2) 15 (62.5) 6 (66.7) 18 (56.3) 48 (61.5) 0.846 No 4 (30.8) 9 (37.5) 3 (33.3) 14 (43.8) 30 (38.5) Receiving formal training
in radiation safety practices in DR
Yes 0 (0.0) 19 (79.2) 4 (57.1) 11 (34.4) 34 (44.7) <0.001 No 13 (100) 5 (20.8) 3 (42.9) 21 (65.6) 42 (55.3) Having concerns about
radiation dose at the department
Yes 2 (15.4) 18 (81.8) 9 (100) 8 (25) 37 (44.7) <0.001 No 11 (84.6) 4 (18.2) 0 (0.0) 24 (75) 39 (51.3) Being familiar with the
ALARA principle
Yes 2 (18.2) 21 (91.3) 9 (100) 20 (66.7) 52 (71.2) <0.001 No 9 (81.8) 2 (8.7) 0 (0.0) 10 (33.3) 21 (28.8)
HA, HB, HC and HD are the different hospitals assessed; HA = King Fahad Hospital, Hofuf, Alhasa, HB = King Fahad University Hospital, Alkhobar, HC = King Fahad Specialist Hospital, Dammam, and, MCH = Maternity and children Hospital, Dammam. CR= Computed radiography, DDR= Direct digital radiography, IDR = Indirect digital radiography, DR= Digital radiography, ALARA = As Low as Reasonably Achievable/Acceptable. Q2 was omitted since all participants were males.
Knowledge regarding use of grids in pediatric radiography
Table 3 illustrates participants’ use of grids in pediatric radiography. Results from HA, HC, and HD show that most (64.2%) participants (HA, HC and HD
contributing 63.6%, 80%, and 73.9%, respectively) agreed that the utilization of grids should be taken only when the thickness of a patient’s body-part is greater than 8-10 cm Most participants from HB did not agree (65.2%).
Advocation for the utilization of grids for
. only abdomen, spine, skull, cross-table
lateral radiographs, pelvis were done by two-thirds of the participants of all the hospitals, with HB being the exception where only half of participants were in favour. Significant differences were found between the participants from different hospitals (p <0.032). Majority of participants from all hospitals agreed that grids are unnecessary for the use of infants and small children (84.7%, P<0.002). Table 3 also depicts that majority of participants from HA and HB reported that grids should be considered in all examinations (62% and 88%, respectively). Significant differences were found among the participants from different hospitals (p <0.001).
Figure 1: Percentage of radiographer participants' response to the statement “Have you acquired precise tutelage in digital radiography of paediatrics?”.
Table 2: Correct response rates among the investigated radiographers regarding pediatric digital radiography. Data shown are frequency; n and (%), and, p values.
Hospital Question
HA HB HC HD Total P
True False True False True False True False True False value The imaging
challenges of pediatric radiography varies from prototypical radiography of adults.
13
(100) - 23
(100) - 8
(100) - 29 (100)
73
(100) - 1.000 Pediatric patients are
believed to be twice as sensitive to ionizing radiation as adults.
7 (64)
4 (36)
12 (50)
12 (50)
8
(100) - 15 (60)
10 (40)
42 (61.8)
26 (38.2) 0.028 Patients of pediatric
age group are thought to be up to 10 times more vulnerable to ionizing radiation compared to adults.
5 (45)
6 (55)
11 (50)
11 (50)
1 (50)
1 (50)
13 (50)
10 (40)
30 (52.6)
27 (47.4) 0.995 For patients below the
age of 15 years, acute radiation exposure is associated with greater than double the normal threat of cancer mortality than for other age group patients.
8 (72)
3 (28)
17 (74)
6 (26)
1 (50)
1 (50)
17 (71)
13 (50)
43 (65.2)
23 (34.8) 0.921
The same radiographic techniques (tube current, X-ray tube potential, source-to- image distance, etc.) utilized for adults can be put in to pediatric patients.
1 (9)
10 (90)
15 (65)
8 (35)
3 (75)
1 (25)
12 (40)
7 (29)
31 (54.4)
26 (45.6) 0.010
Knowledge regarding use of grids in pediatric radiography
Table 3 illustrates participants’ use of grids in pediatric radiography. Results from HA, HC, and HD show that most
(64.2%) participants (HA, HC and HD contributing 63.6%, 80%, and 73.9%, respectively) agreed that the utilization of grids should be taken only when the thickness of a patient’s body-part is
. greater than 8-10 cm Most participants
from HB did not agree (65.2%).
Advocation for the utilization of grids for only abdomen, spine, skull, cross-table lateral radiographs, pelvis were done by two-thirds of the participants of all the hospitals, with HB being the exception where only half of participants were in favour. Significant differences were found between the participants from different hospitals (p <0.032). Majority of
participants from all hospitals agreed that grids are unnecessary for the use of infants and small children (84.7%, P<0.002). Table 3 also depicts that majority of participants from HA and HB reported that grids should be considered in all examinations (62% and 88%, respectively). Significant differences were found among the participants from different hospitals (p <0.001).
Table 3: Use of grids for pediatric radiography among the investigated radiographers. Data shown are frequency; n and (%), and, p values.
Hospitals
Question
HA HB HC HD Total P
Yes No Yes No Yes No Yes No Yes No value
Grids are used for patients with a body-part thickness of more than 8 to 10 cm.
7 (63.6)
4 (36.4)
8 (34.8)
15 (65.2)
4 (80)
1 (20)
17 (73.9)
6 (26.1)
36 (64.2)
20 (35.7) 0.032 Grids are used only
for pelvis, abdomen, spine, skull, and cross-table lateral radiographs.
9 (82) 2 (18)
11 (48)
12 (52)
5 (100)
17
(74) 6 (26) 42 (67.7)
20 (32.3) 0.020 Grids are, in
general, not required for infants or little children.
9 (82) 2 (18.2)
21 (91)
2 (9)
8 (100)
12
(52) 5 (23) 50 (84.7)
9 (15.3) 0.002 Grid use should be
considered for all examinations.
5 (38) 8
(62) 3 (12) 21 (88)
5 (71)
2 (29)
13 (65)
11 (48)
26 (38.2)
42 (61.8) 0.001 Knowledge and attitudes regarding
quality of image optimization and management of dose
The respondents mostly agreed that DR has the prospective to lower the dose of radiation to patients (mean agreement of 3.75). The results showed noteworthy dissonances among the four hospitals (p
<0.001) (Table 4). Participants of HA, HB and HC mostly agreed that radiographers’ lack of familiarity with DR limits its potential (Table 4).
However, HD participants were neutral about this. Chi-squared tests revealed significant differences among the four hospitals (p <0.001). Most participants reported that DR has its own specifications and applications (75%
strongly agreed from HC). Generally, all participants agreed that DR has different types and systems and that each has its own specifications and applications. The majority of participants from HA, HB,
and HC agreed that even though DR has generally improved image quality, albeit, it has also increased the radiation dose (Table 4). Majority of participants from HA, HB and HC (38.5%, 50% and 57.1%, respectively) agreed with the statement “DR has the improved image quality optimization principles than SFR.” The majority of the participants disagreed with the statement “DR has a higher dose than SFR” (p >66.7%).
HA, HC, and HD participants mostly disagreed with the statement “There is problem of dose creep in DR, which elevates the radiation amount as time passes” (mean agreement of 2.18, 2.44, and 2.27, respectively) (Figure 2). HB respondents were more neutral to the statement (mean agreement of 2.54).
However, there were no significant differences among the four hospitals (p
>0.5).
.
Table 4: Participants’ responses regarding digital radiography among the investigated radiographers. Data shown are frequency; n and (%), and, p values.
Hospital
Question HA HB HC HD Total P-
value
Digital radiography has the potential to reduce radiation dose to patients
Strongly disagree 0 (0.0) 1 (4.2) 0 (0.0) 2 (6.5) 3 (4.0)
<0.001 Disagree 1 (9.1) 0 (0.0) 0 (0.0) 8 (25.8) 9 (12.0) Neutral 8 (72.7) 0 (0.0) 2 (22.2) 6 (19.4) 16 (21.3) Agree 1 (9.1) 9 (37.5) 4 (44.4) 10 (32.3) 24 (32.0) Strongly agree 1 (9.1) 14 (58.3) 3 (33.3) 5 (16.1) 23 (30.7) Lack of familiarity by
radiographers in the use of digital radiography limits its potential
Strongly disagree 0 0 (0.0) 0 (0.0) 4 (16.7) 4 (5.9)
<0.001 Disagree 1 (9.1) 0 (0.0) 0 (0.0) 7 (29.2) 8 (11.8) Neutral 2 (18.2) 3 (12.5) 1 (11.1) 11 (45.8) 17 (25.0) Agree 8 (72.7) 19 (79.2) 5 (55.6) 1 (4.2) 33 (48.5) Strongly agree 0 (0.0) 2 (8.3) 3 (33.3) 1 (4.2) 6 (8.8) Digital radiography has a
problems of dose creep which increases the radiation dose over time
Strongly disagree 1 (9.1) 8 (33.3) 3 (33.3) 8 (26.7) 20 (27.0)
<0.001 Disagree 9 (81.8) 2 (8.3) 0 (0.0) 8 (26.7) 19 (25.7) Neutral 0 (0.0) 8 (33.3) 5 (55.6) 12 (40.0) 25 (33.8) Agree 0 (0.0) 5 (20.8) 1 (11.1) 2 (6.7) 8 (10.8) Strongly agree 1 (9.1) 1 (4.2) 0 (0.0) 0 (0.0) 2 (2.7) Digital radiography has
different types and systems and each has its own specifications and applications
Strongly disagree 0 (0.0) 0 (0.0) 0 (0.0) 2 (6.7) 2 (2.7) 0.001 Disagree 0 (0.0) 1 (4.2) 0 (0.0) 8 (26.7) 9 (12.3) Neutral 2 (18.2) 5 (20.8) 1 (12.5) 2 (6.7) 10 (13.7) Agree 8 (72.7) 16 (66.7) 1 (12.5) 9 (30.0) 34 (45.5) Strongly agree 1 (9.1) 2 (8.3) 6 (75.0) 9 (30.0) 18 (24.7) Digital radiography has
generally improved image quality however it increases the radiation dose as well
Disagree 2 (15.4) 1 (4.2) 0 (0.0) 10 (32.3) 13 (17.3) 0.012 Neutral 3 (23.1) 8 (33.3) 0 (0.0) 9 (29.0) 20 (26.7) Agree 1 (7.7) 2 (8.3) 1 (14.3) 6 (19.4) 10 (13.3)
Figure 2: The mean and range of agreement of the investigated radiographers to the statement
“Digital radiography has a prospective dilemma of dose creep, which elevates the radiation amount as time passes”.
The majority of the respondents from different hospitals reported that exposure factors should be selected according to patient size, anatomical region, patient age, and examination/pathology indications. However, the majority of participants (63.1%) selected “DR alters the method of collimation of the beam, as the cropping of the images can be done in DR” (Figure 3).
Figure 3: Percentage of participating radiographers' response to the statement “DR alters the method of collimation of the beam, as the cropping of the images can be done in DR”.
Most of respondents from HA (90.9%) stated that they relied on cropping of image more particularly than collimation to evade image cut. A considerable percentage of the participants from HB and HD (30.4% and 48.1%, respectively) also depended on cropping of the image
. rather than collimation (Figure 4). All
participants from HA and the majority of participants from HB and HC indicated that collimating of the X-ray radiation leads to an unnecessary amount of radiation load to the patient (100%, 52.2%, and 75%, respectively). All participants from HA and the majority of participants from HB and HC (52.2% and 75%, respectively) agreed that beam collimation does not lead to an unnecessary amount of radiation load to the patient. However, the majority of participants from HD (54.2%) reported the opposite (Figure 4).
Figure 4: Percentage of participating radiographers' response to the statement “I depend more on cropping of the image in contrast to collimation to evade cutting off anatomical regions”.
Discussion
The consequence of this study affirms variability in the conception and perspectives of pediatric radiographers from different hospitals. An ethnographic study conducted by Hayre(19) to explore contemporary radiographic practice also showed that some radiographers did not fully understand the technological aspects of DR. Generally, however, the participants from different hospitals did recognize the advantages of DR systems vs. SFR. Although most radiographers who participated in the survey were familiar with the general differences between DR and SFR and among various types of DR, many did not understand how these differences change the practices. For example, the majority of participants from each hospital did not seem aware of the dose creep problem.
The survey also showed that approximately 65% of the participants had a misunderstanding of radiation dose.
Even though most of the radiographers from HB and HC had received proper instructions in radiation relating to its safety, they were unaware of the dose creep issue, which has been shown to exist in clinical practice(6). Dose creep, which is using exposures greater than required for the appropriate image quality, is a significant problem in DR and should be understood by radiographers(20-22). The radiographers tend to, with time, increase the exposure more than required without paying attention to the radiation dose as the quality of the image becomes better. A wide dynamic range, which is an advantage of DR, may cause potential harm, as it allows using a wider range of exposure doses. Lower exposure increases the noise of the images, and higher exposure increases the radiation dose to the patients(20, 21).
Even though the radiographers generally had a good understanding of and positive attitudes toward DR, they seemed unaware that DR could improve the quality of the image quality and decrease the dose of radiation. Most of the radiographers reported that DR upgrades the image quality but by increasing the radiation dose. This contradicted their answers to a previous question comparing DR and SFR, as more than 66.7% of them disagreed that DR delivers a higher radiation dose than SFR. This contradiction demonstrates that the radiographers do not fully understand the properties and limitations of DR. In DR systems, the quality of the image can be maintained while decreasing radiation doses to the patient because of the higher detective quantum efficiency and the advantage of image processing(9, 23). The results also show that a high percentage of the participants from all hospitals (45.6%) relied on image cropping more than collimation. The respondents generally did not consider the importance of employing strict collimation. It is surmised that they took advantage of the image-crop software function to mask improper collimation.
This incorrect practice of using image cropping rather than collimation may be common, as because it is a much easier and faster task and is associated with a
. lower risk of missed anatomy in the
image(19). In recent study, the researchers found that even though the majority of radiographers agreed that collimating of the X-ray radiation is vital in DR, 74.5%
of them did not alter the collimation of the beam, but relied on cropping via post- processing methods(18).
Almost half of the participants did not realize that sensitivity to ionizing radiation of pediatric patients is ten times than adults. This may be explained by the fact that the majority of radiographers (66%) did not have proper tutelage in pediatric DR. This lack of awareness regarding DR properties and the lack of professional competency impacts the delivery of professional practice(19). A significant number of radiographers hailing from both Saudi Arabia and Australia had not acquired precise tutelage in imaging modalities of pediatrics in DR despite agreeing that pediatric imaging is different, challenging and sensitive to radiation compared to adult DR(18).
Conclusion
The findings from the results show that despite that radiographers being aware about the importance about pediatric DR examinations, they do not understand the vulnerability factors and how they impact image quality and radiation amount This highly demonstrates that radiographers need to take part in training to gain further knowledge to improve their understanding and enhance their performance in pediatric DR examination.
The study findings demonstrate the need for training courses to improve radiographers’ practice and performance in DR. The problem of dose creep is not fully understood by radiographers.
Radiographers should consider that the wide dynamic range of DR might lead to unnecessary radiation doses to patients.
The results of this study also emphasize the need to increase radiographers’
awareness of the importance of collimation and the problem of using image crop as an alternative. We recommend providing radiographers with training courses in radiation protection and pediatric imaging, as most of them have not received formal courses.
Limitations of the Study
This study had several limitations. Only four hospitals in Saudi Arabia were considered, and a limited number of radiographers participated. While the focus of this study was in one country and on one demographic group, there may be similar issues in the radiography of adults and pediatric patients in other countries.
As such, a broader study on radiographers’ knowledge of and attitudes toward DR is warranted.
Funding
This study was supported by Imam Abdulrahman Bin Faisal University, and, King Khalid University, as a part of the employment duties of the authors.
Conflict of Interests
The authors declared no conflict of interests.
Author Contribution
All authors imparted some proportion to the formulation, style and composition of the work, and, the accretion, scrutiny and rendition of the data. All authors were intricate in drafting of the manuscript and have approved its final submitted version.
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