Additional accountability when using CT within a Hybrid Imaging Environment

Following some research research and discussions at conferences, the potential impact of using CT within a SPECT/CT examination inappropriately can be a concern for clinical departments. The additional record keeping associated with using a transmission imaging source and potential for detecting incidental findings (e.g. liver mets) is a possibility, even when using low dose CT and the spatial resolution isn't great. This presents an ethical dilemma with regards to the documenting of findings, as under IR(ME)R (2000) all examinations involving the use of ionsing radiation should have an associated report attached.

The use of assistive software, such as "guided SPECT" may offer practitioners greater confidence when setting up the acquisition parameters in a SPECT/CT examination. Familarisation with the SPECT cine may help practitioners, especially those with limited cross sectional anatomy knowledge to set the topogram appropraitely within the CT examination. This is a major consideration for areas where a specific field is required for the CT data set, purely to provide attenuation correction / localisation parameters.

New technology presents many advantages to both patients and practitioners, however appropriate training, familarisation and experience is essential for optimal operation.

I miss being able to talk to my patients...........

Many practitioners prefer not to use the intercom devices within the control rooms of hybrid imaging environments. This appears to go against the grain in terms of traditional nuclear medicine practice, whereby contact with patients is maintained (albeit at a distance) during the clinical procedure.  The advert of hybrid imaging has inevitably created a physical barrier, which protects the practitioner from X-ray scatter radiation produced during the CT aspect of the hybrid procedure. 

Conventionally, the majority of operations to control the actions of a gamma camera would have been conducted using a handset, either hardwired to the system (image below) or via a radio frequency / wifi mode.  Obviously the nuclear medicine practitoner needs to ensure they follow the practical domains of minimising time near a radioactive source, keeping a safe distance from a radioactive source and ensuring adequate shielding is in place to minimise dose and optimise image quality.  The is however a sense of a 'connection' between the patient and practitioner when using the handset, which creates in itself a environment of trust, role identity and autonomous practice. 

Given the advent of hybrid imaging environments, such as SPECT/CT and PET/CT, there is consideration for the safe use of the x-ray source, which is used to create the transmission date for the attenuation correction and anatomical detail (if appropriate) for the fused data sets.  The introduction of an x-ray source has re-shaped the traditional nuclear medicine environment, especially in terms of the creation of a physical barrier and the use of communication intercoms (image below), CCTV and increased automatic / remote position aids for examinations. 

Being able to remotely position aspects of a hybrid scan (especially in PET/CT) is reducing the visible contact with patients, which on one hand is positive from a minimisation of personal dose levels, however practitioners working within these emerging environments are having to remap their working practices, redefine clinical protocols and even redesign departments to accommodate aspects such as dedicated changing rooms for patients. 





Barley's Technology as an occasion for structuring

It's been a while since my last post, so I thought I'd link to something related to my professional doctorate. As part of the literature review section, I came across an article which referred to something called the 'Barley's Technology effect'. Barley wrote a seminal article in 1986 related to the installation and structuring of two CT units in two different imaging departments.

Of particular interest to Barley was the different outcomes for each of the imaging departments, despite having similar organisational structures. Undertaking s subsequent search for other primary based research studies, looking at the effect of introducing technology within the workplace, has resulted in finding a number of articles by Stephen Barley. All the work by Barley relates to understanding the interactions of people within cultures / organisations, following the introduction of technology and / or the symbolic influences within the workplace. Barley's work is cited in numerous research papers and provides a very useful platform for the critical evaluation of work within this field.

SUV calculations and decision making abilities

From my time in clinical PET, I've noticed a variation in the calculations of Standard Update Values (SUV) between different manufacturers software platforms. I'm not sure why this occurs and perhaps it could be down to the use of different calculation algorithms being utilised.

Practitioners, physicists and consultants need to be aware however of the potential for variations in SUV calculations between different manufacturers. It would be interesting to conduct a validated comparison project between different vendors software to assess the potential variations in calculations.  This also highlights to me the need of ensuring practitioners have a strong understanding of quantification within nuclear medicine and in particular hybrid practice.  Ensuring the skills, training and education frameworks are in place is integral to the future of effective / innovative service provision.

Service Redesign in Nuclear Medicine

Developing new services in Nuclear Medicine requires careful planning and the advent of hybrid imaging technology has begun to open new avenues for nuclear medicine practitioners.

It is crucial that the nuclear medicine workforce continues to engage and work with other professions, such as cardiology, oncology and neurology to further promote the clinical value of nuclear medicine and further develop a multiprofessional approach to the whole imaging / treatment landscape.

Trying to convince financial managers to invest in a hybrid imaging system, whether it is to replace your aging gamma camera or as an additional system can be very difficult. Some centres have used the argument that the hybrid system could be used to support radiology workload (e.g. CT heads) and even conduct examinations involving the use of contrast agents. Phrases such as "one stop shop" imaging have begun to emerge where nuclear medicine departments attempt to increase their profile and workload and even perhaps justifying their new imaging system.

Having a hybrid imaging system does provide improved confidence / accuracy for clinicians and new opportunities for the nuclear medicine workforce. However, careful consideration is required to ensure the service redesign places Nuclear Medicine at the heart of the clinical provision.

patient support skills for hybrid imaging practitioners

During a weeks clinical attachment at a regional PET/CT centre in England, I began to realise the patient support skills that are required by nuclear medicine practitioners who work in PET/CT and SPECT/CT. Being able to identify the emotional levels within a patient during the first few moments of contact is crucial.

All practitioners working within an oncology environment learn to adjust their working parameters with each individual patient who requires care and treatment. Equipping nuclear medicine practitioners with patient support skills will ensure they fully appreciate and understand the patient's perspective / current state of mind and hopefully obtain optimal images. I have begun to explore the value of patient support training sessions for hybrid imaging practitioners and basic strategies that could be adopted.

We already use the Health Talk Online website within the programme of nuclear medicine education at the University of the West of England, Bristol and have begun including service users within certain modules. However, the inclusion of specific patient support sessions should further help nuclear medicine practitioners communicate with patients and provide a holistic clinical service.

Blending in Hybrid Imaging

Following some time at a clinical site recently, I noticed the knowledge and understanding required by practitioners in order to create fused image data sets in SPECT/CT and PET/CT. Having the correct amount of CT and PET or SPECT data can really highlight the presence of disease.

Image reviewing can be a subjective aspect of nuclear medicine and knowing how much "blending" is required comes from experience and an understanding of the modalities. This is particularly an issue when selective data sets are sent to PACS for reviewing by consultants.

The advent of "floating" licences has made it slightly easier to view fused hybrid data sets on remote systems, where the user has full access to imaging blending tools.