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ORIGINAL ARTICLE
Year : 2016  |  Volume : 19  |  Issue : 4  |  Page : 502-507

Physician and nurse knowledge about patient radiation exposure in the emergency department


1 Department of Emergency Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
2 Department of Emergency Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
3 Department of Emergency Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
4 Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
5 Department of Emergency Medicine, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea,Seoul, Republic of Korea
6 Department of Emergency Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea

Date of Acceptance23-Nov-2015
Date of Web Publication1-Jun-2016

Correspondence Address:
Dr. S H Woo
Department of Emergency Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, #665-8 Bupyeong 6-dong, Bupyeong-gu, Incheon 403-720
Republic of Korea
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1119-3077.183298

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   Abstract 

Background: Imaging methods that use ionizing radiation in emergency departments (EDs) have increased with advances in radiological diagnostic methods. Physician and nurse awareness of the radiation dose in the ED and the associated cancer risks to which the patients are exposed were surveyed with a questionnaire.
Methods: A total of 191 subjects in six EDs participated in this study. ED physicians and ED nurses were asked about the risks and the radiation doses of imaging methods ordered in the ED. The differences between the two groups were compared using Student's t-test for continuous variables. A Fisher's exact and Chi-squared tests were used for categorical variables.
Results: A total of 82 ED physicians and 109 ED nurses completed the questionnaire; 38 (46.3%) physicians and 8 (7.3%) nurses correctly answered the question about the chest X-ray radiation dose. A question about the number of chest X-rays that is equivalent to the dose of a pelvic X-ray was answered correctly by 5 (6.1%) physicians and 9 (8.3%) nurses (P = 0.571). Questions regarding abdominal computed tomography (CT), chest CT, brain CT, abdominal ultrasonography, and brain magnetic resonance imaging were answered correctly more frequently by the physician group than the nurse group (P < 0.05). The risk of developing cancer over a lifetime due to a brain CT was correctly answered by 21 (25.6%) physicians and 30 (27.5%) nurses (P = 0.170). A similar question regarding abdominal CT was correctly answered by 21 (25.6%) physicians and 42 (38.5%) nurses (P = 0.127).
Conclusions: Knowledge of the radiation exposure of radiology examinations was lower in nurses than physicians, but knowledge was poor in both groups. ED physicians and nurses should be educated about radiation exposure and cancer risks associated with various diagnostic radiological methods.

Keywords: Diagnostic imaging, emergencies, radiation dosage


How to cite this article:
Lee W J, Woo S H, Seol S H, Kim D H, Wee J H, Choi S P, Jeong W J, Oh S H, Kyong Y Y, Kim S W. Physician and nurse knowledge about patient radiation exposure in the emergency department. Niger J Clin Pract 2016;19:502-7

How to cite this URL:
Lee W J, Woo S H, Seol S H, Kim D H, Wee J H, Choi S P, Jeong W J, Oh S H, Kyong Y Y, Kim S W. Physician and nurse knowledge about patient radiation exposure in the emergency department. Niger J Clin Pract [serial online] 2016 [cited 2022 May 18];19:502-7. Available from: https://www.njcponline.com/text.asp?2016/19/4/502/183298


   Introduction Top


A recent disaster occurred at the Fukushima nuclear power plant in 2011. As a result, concerns about radiation exposure and radiation-induced ionization have increased in South Korea. Given its close proximity to Japan, South Korea has activated mass media and Internet communications, and we are interested in radiation exposure in daily life as well as the high dose of radiation in the extensive use of computed tomography (CT) scans in the emergency department (ED).[1],[2]

In recent years, studies have shown a lack of awareness among physicians and radiologists regarding the radiation exposure doses associated with diagnostic radiology procedures. Although many studies have investigated radiation exposure to radiologists and doctors during radiology procedures as well as the knowledge of radiation exposure in patients, there have been very few reports involving ED nurses.[3],[4],[5],[6],[7]

Imaging methods that use ionizing radiation have increased in EDs with advances in radiological diagnostic methods. In particular, the use of these modalities in pediatric emergency rooms has been higher than in other countries, which indicates that in pediatric emergency settings, the use of X-ray and CT scans for diagnostic purposes is closely related to the elevated exposure to ionizing radiation.[8] It is important that emergency physicians who order imaging tests are well trained in determining whether diagnostic imaging is required but also that emergency physicians have an accurate knowledge of the associated risks to patients. This is particularly important in the ED, where many radiological imaging tests are ordered and rapid decisions are needed.

The cooperation of nurses in the ED, who closely manage patients, is essential for performing radiological diagnostic procedures and for obtaining informed consent from patients and their families. Both physicians and nurses play important roles in the decisions regarding emergency diagnostic procedures and treatments.

However, despite the increased exposure of patients to radiation in the ED with advances in radiological diagnostic methods, radiation safety education is not standard in ED training programs in South Korea and may be lacking.

The aim of our study was to analyze and compare the awareness of ED physicians and nurses regarding the radiation doses and the associated cancer risks to which the patients are exposed due to radiological diagnostic procedures in the ED.


   Methods Top


This study was conducted in the six EDs of the University Hospital in South Korea and was approved by the Institutional Review Board of the Catholic University of Korea. The doctors and nurses of ED (Incheon St. Mary's Hospital, Yeouido St. Mary's Hospital, St. Vincent's Hospital, Seoul St. Mary's Hospital, Uijeongbu St. Mary's Hospital, and Bucheon St. Mary's Hospital) were the subjects of this survey. The annual average number of visiting patients in Seoul St. Mary's Hospital and the other four EDs in Gyeonggi-do was greater than 50,000 and at Yeouido St. Mary's Hospital, it was over 35,000. Seoul and Incheon St. Mary's Hospitals are tertiary care hospitals and the other four hospitals are secondary care hospitals. These emergency centers are all teaching hospitals that provide medical care to pediatric, adult, and trauma patients.

The data were collected anonymously from 95 doctors and 124 nurses. In total, 24 did not agree to the survey; 4 replied incompletely and their partial responses were not included. A total of 191 subjects participated in the study, with 82 (42.9%) ED physicians and 109 (57.1%) ED nurses answering the questions.

The study consisted of questions regarding the participant's demographics and radiation knowledge, with 15 questions testing the actual knowledge of radiation doses [see Appendix]. Questions were designed by emergency physicians (staff, professors) and were agreed upon by all authors. The questions were in short answer and multiple choice formats, each with one correct answer. To assess the radiation dosing knowledge, participants were asked to estimate chest X-ray equivalents. Some questions also addressed organ sensitivity and the risk of fatal cancers from a CT scan. The dose and amount of radiation exposure from diagnostic imaging techniques in the ED may differ by hospital, rural area, urban area, and country. The survey questions were based on previously published studies.[3],[4],[5],[6],[7] Recruitment occurred between May and June 2012 in the six EDs. Responses to questions in a standard written form were completed in their ED of each teaching hospital under the strict control of coauthors. Each questionnaire was completed within 10 min without references or books. The research staff was excluded. Scoring of the survey was performed by an independent coordinator, unrelated to this particular survey.[Additional file 1]

SPSS software (SPSS, Chicago, IL, USA) was used for the statistical analysis. The differences between the two groups were compared using Student's t- test for continuous variables. Chi-squared and Fisher's exact tests were used to assess categorical variables. P values less than 0.05 were considered to be statistically significant.


   Results Top


General characteristics of the subjects

Twenty-two (26.8%) of the physicians and 107 (98.2%) of the nurses were female. For the questions about natural radioactivity, 81 (98.8%) of the physicians and 100 (93.5%) of the nurses recognized (P = 0.031). The mean age of the participants was 29.76 ± 5.98 years. The mean ages of the physicians and nurses were 31.12 ± 6.25 and 28.73 ± 5.57 years, respectively (P = 0.006). The employment duration was more than 5 years after graduation for 22 (26.8%) of the physicians and 44 (40.4%) of the nurses. The employment level of the physicians in this study revealed that 34 (41.5%) were interns, 26 (31.7%) were residents, and 22 (26.8%) were staff [Table 1].
Table 1: Distribution of the demographic features of the ED physicians and nurses

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The results showed that 27 (32.9%) physicians and 17 (15.6%) nurses had received education about the radiation doses that patients are subjected to and their potential risks within the past 5 years (P = 0.005).

Analysis of physician and nurse knowledge regarding radiation doses

The analysis showed that 38 (46.3%) physicians and 8 (7.3%) nurses correctly answered the question regarding chest posterior–anterior (PA) radiation dose (P < 0.001). The radiation dose in mSv from a single chest X-ray was overestimated by 18 (22.0%) physicians and 20 (18.3%) nurses (P = 0.537).

A question about the number of chest PAs that are equivalent to the dose of a pelvic X-ray was answered correctly by 5 (6.1%) physicians and 9 (8.3%) nurses, whereas 77 (93.9%) physicians and 97 (89.0%) nurses underestimated the radiation dose (P = 0.262).

In addition, 20 (24.4%) physicians and 7 (6.4%) nurses correctly answered the question about the corresponding number of chest X-rays with respect to the received radiation dose of an abdominal CT (P < 0.001). The same question regarding chest CT and brain CT was answered correctly more frequently by the physician group than the nurse group (P < 0.005) [Table 2]. Forty-five (54.9%) physicians and 83 (76.1%) nurses underestimated the radiation dose from brain CT scans (P = 0.006). Moreover, 49 (45.0%) nurses, 88 (80.7%) nurses incorrectly answered the question about the radiation dose of abdominal ultrasonography (US) and brain magnetic resonance imaging (MRI) (P< 0.001).
Table 2: Distribution of correct answers regarding the corresponding number of chest X--rays with respect to the received radiation doses during diagnostic imaging studies (n, %)

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The lifetime risk of developing cancer due to a brain CT was answered correctly by 21 (25.6%) physicians and 30 (27.5%) nurses. The same question regarding abdominal CT was answered correctly by 21 (25.6%) physicians and 42 (38.5%) nurses; 43 (52.4%) physicians and 43 (39.4%) nurses overestimated the lifetime attributable risk of fatal cancer from a single abdominal CT scan (P = 0.127). However, the risk of a brain CT was underestimated by 42 (51.2%) physicians and 65 (59.6%) nurses (P = 0.170) [Table 3].
Table 3: Distribution of correct answers regarding the lifetime cancer risk from CT

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The optimal period of education of 1 year was identified by 37 (45.1%) physicians and 67 (61.5%) nurses.

In addition, 72 (87.8%) physicians and 78 (71.6%) nurses stated that they explain the risks of radiation to pregnant women in the ED prior to diagnostic radiological imaging [Figure 1]. However, regarding brain CT in pediatric patients, 4 (4.9%) physicians and 14 (12.8%) nurses stated that they do not agree that they explain the radiation risks to patients adequately in the ED [Figure 2]. Regarding adult brain CT, 15 physicians (18.3%) and 14 (12.8%) nurses stated that they do not agree that the radiation risks are adequately explained to patients in the ED [Figure 3].
Figure 1: Regarding X-rays in pregnant patients, do you agree that we explain the radiation risks adequately in our emergency departments?

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Figure 2: Regarding brain computed tomography in pediatric patients, do you agree that we explain the radiation risks adequately in our emergency departments?

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Figure 3: Regarding computed tomography in adult patients, do you agree that we explain the radiation risks adequately in our emergency departments?

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   Discussion Top


Recently, South Korea has shown a high interest in radiation exposure after the Fukushima nuclear plant disaster in Japan. Patients visiting the emergency room have a right to the facts about the radiation exposure amounts in diagnostic and therapeutic procedures. Therefore, emergency physicians and nurses should know about the radiation exposure doses of all diagnostic imaging procedures. In addition, an increased number of major trauma patients have increased radiation exposure because they require rapid CT for rapid diagnosis and active critical care.[9] A report by Ott et al., explained that the majority of minor trauma patients are exposed to too much radiation from X-rays and CT scans prior to their diagnosis; a reduction in the radiation exposure during diagnosis is necessary.[9] Therefore, radiation-based diagnostic procedures should be reduced to minimize the radiation exposure in the emergency room, and explanations should be provided to patients regarding the amount of radiation exposure and any related complications.

According to Lee et al., over 70% of radiologists and emergency physicians underestimate the amount of radiation exposure from CT scans, and 91% of emergency physicians explained that radiation exposure has no relationship to the increased cancer incidence rate, so that they ignore the radiation risks.[10] In this research, the majority of physicians and nurses acknowledged the risk of radiation exposure to fetuses and pregnant women and explained these risks before the radiology examinations. However, this was not the case for pediatric patients. Children may be exposed to more radiation as they grow, and they therefore need more attention when diagnostic X-rays or CT scans are required. The cumulative effects of radiation exposure over multiple diagnostic imaging methods affect the risk of cancer development in pediatric patients.[11],[12]

Both the physicians and nurses underestimated the radiation dose of brain CT in this study. Adult and pediatric patients present to the ED because of blunt minor or major head trauma. Thus, primary physicians in the ED should employ brain CT for diagnosing major head injuries. In addition, they should consider the necessity for CT in mild head trauma in pediatric cases. The rate of abdominal CT use has been increasing due to the more accurate diagnosis of appendicitis in children.[13],[14],[15] Physicians should have sufficient knowledge about the radiation dose of diagnostic radiological examinations and work to decrease the radiation exposure of children in the ED.

Knowledge regarding the radiation dose for a abdominal CT, chest CT, and brain CT was evaluated in relation to the corresponding number of PA chest X-rays: 20 (24.4%), 16 (19.5%), and 30 (36.6%) physicians and 7 (6.4%), 7 (6.4%), and 19 (17.4%) nurses, respectively, correctly answered this question. An investigation of previous studies revealed that the ratio of the correct answers to these questions was as low as in our study.[3],[4],[5] Most patients or their guardians visiting the ED lack knowledge of the radiation doses that they may be exposed to during diagnostic radiological examination. Thus, to decrease the radiation exposure dose of the patient in the ED, everyone (physicians, nurses, patients, and their guardians) need to increase awareness of radiation risks. Exposure to radiation as a result of a radiologic examination in the ED may be associated with an increased risk of malignancy.[16],[17] The risk of malignancy was overestimated in abdominal CT but underestimated in brain CT by both physicians and nurses. Emergency physicians order brain CT for the diagnosis of most major head trauma patients, but they underestimated the radiation exposure regarding the risk of malignancy in adults. CT is the source of increasing radiation exposure in the ED. Radiation-induced cancer risks from CT must be addressed more thoroughly in the ED.

There are several limitations of this study. The survey was performed only at university-affiliated teaching institutions in South Korea. Knowledge of the radiation dose in physicians and nurses may differ based on local variations in each institution's education program. The survey validation was limited to confirmation of the answers by the coauthors. In addition, the survey was performed at six teaching hospitals. Several participants did not complete the survey, leading to missing data. The estimated radiation dose of the diagnostic imaging technique and cancer risk showed controversial results in previous studies.[18],[19],[20],[21] It may be difficult to assess the actual individual knowledge about radiation doses in the ED from this survey. Thus, we need further evaluation from a larger survey of ED personnel in the future. However, this study showed knowledge differences between physicians and nurses in the ED; the actual awareness of radiation exposure of radiologic examination might be lower in nurses than tested.

The question regarding the radiation dose of abdominal US and brain MRI was frequently answered incorrectly by the nurses. In the emergency room, physicians, nurses, and paramedics should work as a team in urgent clinical situations to rapidly diagnose and treat patients. Therefore, the nurses and paramedics who work in the emergency room should be educated about the differences in the radiation doses of different radiologic diagnostic evaluations. Our study indicates a need for additional education regarding radiation risks. Increased awareness of physicians and nurses regarding the radiation dose and radiation risks of radiological imaging methods may be achieved with a new education program in EDs.


   Conclusions Top


In the emergency room, the awareness of radiation exposure of radiologic examination was lower in nurses than in physicians. However, the knowledge of ED physicians and nurses about the risks and doses from radiation exposure in the ED was poor. ED physicians and nurses may benefit from standardized continuing education programs about radiation exposure due to radiological diagnostic methods and their associated cancer risks.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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Oh HY, Kim EY, Kim JE, Kim YJ, Choi HY, Cho J, et al. Trends of CT use in the pediatric emergency department in a tertiary academic hospital of Korea during 2001-2010. Korean J Radiol 2012;13:771-5.  Back to cited text no. 8
    
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Hryhorczuk AL, Mannix RC, Taylor GA. Pediatric abdominal pain: Use of imaging in the emergency department in the United States from 1999 to 2007. Radiology 2012;263:778-85.  Back to cited text no. 14
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]


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