Background
The image quality of a chest radiograph has a direct effect on its interpretability. Correct patient position, image brightness, and image contrast are essential for a high quality chest radiograph. Disparities in approaches to paediatric imaging between countries include variations in the availability and maintenance of equipment, the use of non-standard methods such as fluoroscopy as routine practice, and different training and experience of personnel. These factors, combined with the absence of a centralised resource on the safe acquisition of chest radiographs for children, has led to vast differences in image quality between facilities.
Our work
An objective of the WHO CRES project was to develop quality and safety resources for the safe acquisition of chest radiographs from children aged between 0 and 59 months. The resources developed bring together guidelines from various international organisations, published best practice techniques, and expert experience. A framework was constructed and refined following input from the WHO CRES technical working group. The technical working group emphasised the need for collaboration between radiology staff and research staff, and prioritized content that was developed into the current resources.
These resources are targeted specifically at remote and under-resourced regions, although there is scope for their use at any level. The recommendations are not intended to be prescriptive, but assistive, allowing flexibility for facilities to operate within their capabilities. It is expected that these resources will be used by only those who have the capacity to initiate such measures, either through self-funding or through study funding. It is intended that the resources will be broadly used to maximise consistency between images and the potential success of interpretation for epidemiological studies.
These resources are split into three phases:
An assessment of individual radiology facilities to determine their suitability for inclusion within a study. Technical and workflow parameters are evaluated, allowing the research team to calculate the amount of funding required to reach the necessary standard for participation. This standard is based on the quality of the chest radiographs and each facility is required to provide a random sample of 50 images for quality evaluation.
Reviews the major factors contributing to quality paediatric chest radiographs and identifies issues that are most important and/or require adjustment by the research team. Provides recommendations that are flexible to the individual needs of study researchers. Recommendations have been developed from best practice techniques according to current literature and international regulations. The guidelines are categorized into 6 broad domains and include two instructional positioning videos (see below):
- Personnel qualifications and experience
- Facility infrastructure
- Equipment specifications
- Image labelling and identification
- Chest radiograph acquisition positioning and parameters
- Image archiving and reading
A quality assurance program is designed to measure performance and ensure continual optimisation of equipment and facility processes. Whilst it is recognized that implementation of such a program will be challenging in under-resourced regions, an effective program will result in fewer equipment faults, with reduced downtimes and overall costs. This program is divided into 3 main categories:
- Equipment maintenance and quality control
- Patient dose monitoring
- Image quality critique and reject analysis
Included within the program are suggested instructions, worksheet templates, checklists and task frequency.
These resources are targeted specifically at remote and under-resourced regions, although there is scope for their use at any level. The recommendations are not intended to be prescriptive, but assistive, allowing flexibility for facilities to operate within their capabilities. It is expected that these resources will be used by only those who have the capacity to initiate such measures, either through self-funding or through study funding. It is intended that the resources will be broadly used to maximise consistency between images and the potential success of interpretation for epidemiological studies.
Supine Chest X-ray