Marla B.K. Sammer, MD, MHA, FAAP, Chair of the ACR® Pediatric Quality and Safety Committee under the ACR Pediatrics Commission, discusses how quality and safety differs for pediatric patients relative to the adult population. She also highlights what the ACR is doing to tailor guidelines, accreditation and other resources to help radiologists minimize radiation exposure for children and optimize imaging protocols based on age and size.
How does quality and safety differ for pediatric patients relative to the adult population in radiology?
Dr. Sammer: For pediatric quality and safety, the number one thing is that pediatric patients encompass a range of ages. A newborn is very different from a 17-year-old and also different from a 3-year-old. Each group of pediatric patients has its own specific quality and safety needs. One of the first building blocks is looking at what each of those different groups need. With some, for example, we need to be more concerned with whether or not they need sedation before imaging, or whether or not you have to get their cooperation and immobilization.
Beyond that, there are some key issues around ways to image pediatric patients differently. There are concerns with radiation risk. Radiation exposure accumulates over a lifetime, and children have longer to live. They also have more radio-sensitive tissues. So, we are much more appropriately cautious about using radiation and try to use as low a dose as reasonably achievable. That includes using different modalities with children, such as ultrasound and MRI. Even with the same symptoms or disease process, we might image completely different in pediatric patients.
The ACR Appropriateness Criteria® (AC) are published to enhance quality of care and contribute to the most efficacious use of radiology. What is unique about pediatric imaging guidelines?
Dr. Sammer: Because of the vast array of age ranges and complications and risks that factor into pediatric imaging, the ACR AC contains many pediatric-specific guidelines, and there are more being developed under the ACR pediatric leadership team. For example, we have different guidelines for an adult patient with suspected osteomyelitis versus a child. There are actually different guidelines based on the patient age, which take into account what is feasible for imaging. There are also different disease processes. For example, the way that osteomyelitis presents in a young child is very different than in a 17-year-old. So, the guidelines for imaging are specifically age-based. There are many other AC that are broken out by age, both because of disease presentation and because there are specific diseases that are only seen in pediatric patients.
What is sparking increased development of new pediatric guidelines and other resources for pediatric radiologists?
Dr. Sammer: Of course, we’re always developing more knowledge and learning new things as we work in medicine, but many of the new guidelines are driven by ACR members who need guidance in certain areas. For example, if you’re using the AC for clinical decision support (CDS), you can't just translate adult guidelines to pediatric patients for CDS. Pediatric radiologists requested, and also volunteered to work with the ACR on, appropriateness guidelines for those requirements.
We are also working on things like developing more educational resources related to pediatric imaging, such as a new pediatric incidental findings paper. Members of the ACR Pediatric Quality and Safety Committee have written a roadmap to address incidental findings in pediatric patients. Until now, most of the incidental findings publications are intended for adult use. The paper is intended to let everyone know there are specific guidelines for incidental findings in pediatric patients and advice for how to address those findings in a pediatric patient as compared to an adult.
What is the committee doing with Practice Parameters and Technical Standards (PP&TS) relative to pediatric care?
Dr. Sammer: Most PP&TS that are applicable for children have pediatric-specific content. If the PP&TS are applicable to a pediatric patient, we’re continuing to work to update them to make them even more specific. For example, we’re working on the pediatric perspective for a new practice parameter for AI in radiology. We’re including clarification about pediatric patients, because AI tools shouldn’t be used in children unless specifically validated in pediatric patients, at a minimum. In addition, you need to make sure that it works for each age, not just the entire range from newborn to age 18. So, there will be specific pediatric considerations included as part of the practice parameters for AI.
When it comes to ACR Accreditation, what are some challenges unique to pediatric imaging and what is the College doing to address that in the accreditation program?
Dr. Sammer: With imaging pediatric patients, it can be more difficult to get optimal images. For example, with ultrasound accreditation, there's a specific protocol and specific images you're supposed to provide. With a child who has difficulty cooperating, we do the best we can to provide a diagnostic study to answer the question, but we can't always optimize all the settings as specified for accreditation. So, it can be more difficult to get the correct images.
Another challenge is CT accreditation at children's hospitals, because there are many fewer CTs performed there compared to mixed adult and pediatric facilities. So, it can be difficult to find the required exams for accreditation. Then there are other challenges like the fact that oral contrast might be recommended for a particular study, but that's not done typically at children's hospitals. If oral contrast is recommended or preferred for a study and the accreditation process asks for those studies, children's hospitals won’t be able to provide them. So, rather than give up on accreditation, we want to work with facilities to make sure they know how to reach out and discuss it.
Our committee is gathering and providing feedback to the accreditation program about the overall differences in what is recommended for accreditation versus what's actually being done at children's hospitals and for pediatric imaging at all facilities. We’re providing language and offering recommendations to ensure the accreditation process is viable for all. It’s not intended to be punitive, prescriptive or inflexible.
What is the call to action around pediatric quality and safety for the radiology community?
Dr. Sammer: We want everyone to know that ACR has multiple resources and tools for pediatric radiologists. And we’re always looking for engagement by members to ask questions, provide feedback and volunteer at whatever capacity they can offer. Maybe it’s something micro like submitting a suggestion for a pediatric AC topic, or perhaps it’s volunteering for the ACR Pediatric Quality and Safety Committee. It might even be as simple as making your voice heard at an upcoming virtual meeting for PP&TS. Whatever contribution you can make, we welcome your input to help us improve pediatric quality and safety for our patients.
