Assessment of X-Ray Rejected Films and Image Quality in Diagnostic Radiology Departments of Teaching Hospitals in Iraq

doi:10.21203/rs.3.rs-2949368/v1

Background

Patients undergo repeated X-ray examinations after their initial X-ray radiographs are rejected due to poor image quality. Reject analysis in digital radiography (CR) helps guide the education and training of staff, influences department workflow, reduces patient dose and improves department efficiency. The role of reject analysis in providing relevant information that would help achieve a sound reduction in radiation exposure.

Aims

To assess the reasons for x-ray film rejection & to analyze reasons for deletions to improve the radiological services.

Methods

The data were collected from about 200 rejected films from different hospitals in Iraq from January 2021- August 2021. The reject rate, reasons for rejection for individual radiographers, examination types, and projections used a structured format on which investigators recorded relevant data for rejection. The results were then collected and entered into a database for analysis.

Results

200 radiographic images were acquired and included in the analysis. Reject rate and cause of rejection were measured across all plane x-ray examinations for the hospitals in Kirkuk general hospital at 8.1%, Mosul General Hospital at 13.9%, and Al-Jumhory Hospital at 6.4%. Study cases and (appointment) 16.1%, Mass & Kv with positioning error 3.7%. The examinations with the highest percentage of deleted images were the chest, lumber spine & knee joints, 13.2%, 3.2% & 1,7%, respectively.

Conclusions

Creating awareness among the student reduces the overall reject rate. The outcome of this study can be used to set up training programs to improve radiological services and reduce unnecessary radiation exposure to patients.

Exposure

reject analysis

unnecessary radiation

reasons for rejection & reject rate

A diagnostic radiology facility is any facility where an X-ray system irradiates any part of the human body for diagnosis or visualization. In radiological procedures involving X-rays, patients and staffs are exposed to varying radiation doses. The quality of information obtained from radiographs depends on several factors. (Watkinson et al. 1984)

In diagnostic imaging, one of the main goals of a quality assurance (QA) program is to produce consistently high-quality radiographs at a minimum exposure to the patient ( Jones et al., 2015). Reject analysis is a complementary part of the QA program in a radiology department. (Taylor N 2015, Erturk SM et al. 2005 & Owusu-Banahene J et al. 2014).

The nature and extent of this program will vary with the size and type of the facility and the type of examinations conducted. The main goal of a diagnostic quality assurance program is to produce radiographs of consistently high quality (ICRP, 1990).

The System of Radiological Protection aims to achieve the most protection possible from Ionizing Radiation. There are three Fundamental Principles of Radiological Protection (justification principle, optimization principle, and limitation principle)(“The Recommendations of the International Commission on Radiological Protection. ICRP publication 103,” 2007).

Radiation can induce cell killing if the dose exceeds a certain threshold; frequency and severity increase with the dose, causing cataracts, skin damage, nausea, vomiting, sterility, epilation, etc. (Jiao et al., 2022, Al-Qabandi and Alshammary, 2022).

The recommendation is that one mistake in radiography is sufficient to deprive the patient of using diagnostic rays for not a short period. The patient may need a diagnosis necessary for a chronic disease or an emergency and cannot use it(Lin et al., 2016).

Students in different hospitals carried out the study, but it included a study of quality management on the scale of one hospital for each similar study. This study will link quality management and awareness of patients and workers in radiology departments to the scale of a group of hospitals (Otayni et al., 2023)(Alyousef et al., 2019; Sadiq et al., 2017).

Design:

This study was done for the first time in Iraq; a retrospective longitudinal study of data collected from January 2021- August 2021 was undertaken as part of a clinical audit. 200 rejected films from different hospitals.

Setting:

The data were collected from different hospitals of medical imaging departments in Iraq. Mosel General Hospital n = 74 (13.9%), Kirkuk General Hospital n = 43 (8.1%), AL - Jmhory Hospital n = 34 (6.3%), Emergency Kirkuk Hospital n = 18 (3.4%), Azady Hospital n = 17 (3.2%), Alkhansa Hospital n = 15 (2.8%), X-rays per annum in 2021. The Hospital medical imaging departments consist of fixed DR and a DR mobile machine.

Procedure:

The data were collected using rejected data collection and analysis, which came as a standard component of the CR system. When an image was rejected, the radiographer was prompted to select a reason for rejection before another image could be taken.

Data analysis:

Data was completed using standard descriptive statistics on Microsoft Excel and IBM SPSS Statistics 26. The average reject rate was calculated by dividing the total number of rejected images by the total number of images acquired and expressed as a percentage, along with the standard deviation. The data were filtered, the mean and standard deviation were calculated, and the results were expressed as percentages to assess the reasons for image rejection, the reject rate for each examination type and projection, and individual radiographer reject rates.

Ethics approval and consent to participate:

Local ethics committees have approved the included studies (Hawler Medical University- College of Medicine).

We have noticed that the hospitals rank first in rejecting and repeating X-rays: Kirkuk general hospital 8.1%, Mosul General Hospital 13.9% and Al-Jumhory Hospital 6.4%, as shown in Table (1).

Table (1): Rejection at a hospital (films analysis)

Hospital	frequency	percentage %	valid percentage	cumulative percentage
K.G.H.	43	8.1	8.1	8.1
M.G.H.	74	13.9	13.9	22.0
E.K.G.H.	18	3.4	3.4	25.4
Iben-Sena H.	2	.4	.4	25.8
Al-khansa H.	15	2.8	2.8	28.6
Azadi H.	17	3.2	3.2	31.8
Al-jumhory H.	34	6.4	6.4	38.2
Talafer H.	3	.6	.6	38.7
X-ray CLINIC	2	.4	.4	39.1
Sadder Clinic	1	.2	.2	39.3
K: Kirkuk, M: Musol, H: hospital, E: emergency.

These data indicate considerable variation in the reject rates between individual radiographers. The radiographers in the study represented various levels of experience and utilized their own personal assessment of image quality based on technical and diagnostic qualities.

Table (2): Most examinations rejected (films analysis)

Valid	Frequency	percentage %	Valid percentage	Cumulative percentage
Chest -ray	72	13.5	14.0	14.0
C.S.X-ray	10	1.9	1.9	16.0
L.S.X-ray	17	3.2	3.3	19.3
Skull	5	.9	1.0	20.2
Knee joint	9	1.7	1.8	22.0
Elbow joint	7	1.3	1.4	23.3
Hand X-ray	11	2.1	2.1	25.5
Ankle joint	9	1.7	1.8	27.2
Shoulder	6	1.1	1.2	28.4
Wrist joint	4	.8	.8	29.2
Pelvis	3	.6	.6	29.8
Foot	2	.4	.4	30.2
Assessment of fracture	7	1.3	1.4	31.5
Computed tomography	11	2.1	2.1	33.7
Dental	323	60.7	62.8	96.5
Hip joint	1	.2	.2	96.7
S. spine	1	.2	.2	96.9
Unknown	5	.9	1.0	97.9
k.U.B.	11	2.1	2.1	100.0

Most examinations that have more probability of repeating the films are chest X-ray 13.5%, lumber spine 3.2%, kidney ureter bladder X-ray, and extremities, as shown in Table (2) and Figure (1).

The most common causes of rejection are appointment 16.1%, Positioning, Mass & Kv 3.7% also because of the high number of patients at the same time coming to radiology departments as shown in Table (3) and Figure (2).

Table (3): Causes of rejection (films analysis)

Valid	Frequency	Percentage %	Valid Percentage	Cumulative Percentage
Jewellery and metallic objects	7	1.3	1.3	1.3
Appointment	91	16.9	16.9	18.2
Mas and kvb	20	3.7	3.7	34.8
Hardware failure	1	.2	.2	35.0
An exchange between two patients	3	.6	.6	35.6
Cervical pad artefact	2	.4	.4	35.9
Positioning	20	3.7	3.7	39.7

Different hospitals give us enough responses (Radiology staff) to make a statistical analysis of their responses, Table (4) and Figure (3).

Table (4): Rejection at a hospital (Responses from radiology staff)

Valid	Frequency	Percentage %	Valid Percentage	Cumulative Percentage
C.M.C. H.	7	13.7	13.7	13.7
B.M.C	25	49.0	49.0	62.7
IBEN-SENA H.	2	3.9	3.9	66.7
Al-khansa H.	2	3.9	3.9	70.6
Rezgari H.	7	13.7	13.7	84.3
S.G.H	6	11.8	11.8	96.1
T.G.H.	2	3.9	3.9	100.0
B.M.C: Baghdad medical city, H.: hospital, S.G.H: Salahuddin general hospital, T.G.H.: Tikrit general hospital

31 respondents indicated that the largest percentage of rejection occurs with infants and children, 17 indicated that it occurs with adults and 8 only with older patients, as shown in Table (5) and Figure (4).

Table (5): Rejection according to age (Responses from radiology staff)

Age	Frequency	Percentage %	Valid Percentage	Cumulative Percentage
infant and Childs	31	55.4	55.4	55.4
Adult	17	30.4	30.4	85.7
Older	8	14.3	14.3	100.0

As indicated in this study, the knowledge about the X-ray effect is also missed. Hospitals have no quality assurance to manage and supervise the daily spending films to compare it with patient numbers. When we collect the data, there are no immobilizer tools such as Pigg-o-stat or cervical pad and no portable device for emergency patients in more hospitals(Foos et al., 2008; Yousef et al., 2014).

Our study shows that about 75 frequently rejected chest X-ray films, equal to 37.5% of collected films, which is nearly equal to all collected films of another research (Akhtar et al., 2008; Martin, 2012). As shown, most hospitals re-filming x-ray patients are teaching hospitals under and over-exposure, patient positioning and machines problems similar to Mohammed Yousef's research (Awad et al., 2021).

When we compared the rejected films with other research, we found different results and, in each research, according to the objective of the research and the data collected(Owusu-Banahene et al., 2014). with the average natural background radiation per year, we found that a lot of excessive X-rays absorbed from different patients can be avoided by good management and posters that can educate the patients and reminder staff how they can protect themselves and their patients from excessive radiation(Alahmadi et al., 2019; Hofmann et al., 2015).

At educational health institutions, the devices used are realistic and give a real X-ray rather than educational devices, which can reduce excessive X-ray doses to the students because most examinations that were taken were not necessary but just for the study final test and for a healthy people, not for a patient. There are a lot of techniques of other specializations working on X-ray machines to fill the shortage of radiation, and they haven’t enough experience in dealing with equipment and patients (Atkinson et al., 2020). Another cause of the increasing number of rejected films is that training and development units are almost ineffective. There are a lot of techniques of other specializations working on X-ray machines to fill the shortage of radiation. They haven’t enough experience to deal with equipment and patients, and it's near to be due to one of the references about quality control at the radiology department (Mount, 2016; Seibert and Morin, 2011; Zewdu et al., 2017).

As the study showed, the rejected films can be caused by different factors (patient motion, experience deficiency, equipment deficiency). Some special considerations are necessary for these radiology departments can decrease rejection and improve these departments.

Educational posters are attached to the X-ray departments for patients.
Activating the training and development departments in hospitals.
Each worker should be at his true place
Filling the shortage in the radiology sector

Acknowledgements: Thankfully for those who help me for collecting data and preparing this study (Ali H. Awaad, Faya H. Mustafa, Hanen U. Ismail, Qatar Al-nada N., & Yasir K. Husain. /B.Sc. Radiological Technology/X-Ray/Ketab University).

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No competing interests reported.

Assessment of X-Ray Rejected Films and Image Quality in Diagnostic Radiology Departments of Teaching Hospitals in Iraq

Status:

Version 1

Abstract

Figures

Introduction

Methods

Design:

Setting:

Procedure:

Data analysis:

Results

Discussion

Conclusion

Recommendations

Declarations

References

Additional Declarations

Status:

Version 1