Impact of hybrid imaging on patient management

The use of a hybrid imaging technique such as SPECT/CT or PET/CT may bring advantages to the overall patient management that may have not been initially forcasted.  From working alongside clinical nuclear medicine practitioners, there is a degree of 'incidental findings' that may occur within a hybrid imaging procedures.  Questions that immediately come to mind in this situation:

1) What are the ethics and clinical protocol/s associated with this sort of situation?
2) How are nuclear medicine practitioners trained to spot the incidental findings?
3) Can autonomous practice be adopted by practitioners, to enable them to fully utilise the diagnostic capabilities of hybrid imaging (e.g. Intravenous Contrast injection)?


There is also the matter of reporting the resultant images and ensuring the data sets acquired match highlight any additional information. 

Early adoption theory

I have begun to explore the role of 'technology ownership' within a community, such as nuclear medicine / hybrid imaging.  The introduction of new technology, such as hybrid imaging components and software has resulted in a potential shift in the ownership of such technology. 

Who actually owns this new technology and who are the early adopters? 

Early adoption theory (Rogers, 1971) highlights the percentage of people who readily accept new technology and those who 'lag'.  This is often referred to as 'cultural lag' and may demonstrate itself in varying degrees across the workforce and at a variable pace across different clinical environments

It's like being on an aeroplane!

This blog relates to comments made by practitioners working within hybrid imaging environments, liking them to being on an aeroplane.  Given the advent of hybrid imaging equipment, the footprint of most clinical imaging environments have increased, due mainly to the additional space required for the Y-axis travel of the patient handling system (couch) and cooling specifications for the CT unit. 

The noise generated by some SPECT/CT systems (air cooled) is loud and patients are forewarned before they enter the clinical imaging environment.  This is a positive action and patients are given a full explanation of the procedure before they are injected with the radioisotope and a recap is normally provided before entering the clinical room.  However, the frequency of working practice within the clinical SPECT/CT or PET/CT room by the hybrid practitioner has created a new mode of operation, in terms of the unspoken dialogue, using mnemonics, such as 'P-scope' to describe the persistence scope and phrases such as 'what's your clicks?' to highlight the individual dose level on the personal dosimeters in PET/CT. 

Other non-verbal communication modes are also beginning to shape given the advent of noisy hybrid imaging environments, such as the use of what can only be described as a form of sign language to initiate imaging procedures, or the use of the intercom by some practitioners to warn other practitioners to vacate the imaging environment, as a CT exam is about to commence.  This is in additional to the inclusion of bright lights and environmental monitoring systems in ceilings and pathways carved out in the corridors to inform radioactive patients which is their resting bay (images below). 


   



There is a need for practitioners to evolve their working practices within the hybrid environment so is does not become technocentric.  The imaging procedure needs to revolve around the patient, i.e. be patientcentric.

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.