ASN Report 2020

Teleradiology involves many responsibilities which must be specified in the agreement binding the practitioner performing the procedure to the teleradiologist. The teleradiology procedure is a medical procedure in its own right, like all other imaging procedures, and cannot be reduced to a simple remote interpret­ ation of images. Teleradiology therefore fits into the general health care organisation governed by the Public Health Code and obeys the rules of professional ethics in effect. The Teleradiology Charter published by the French professional council of radiology (G4) was re-updated in 2020. This fourth version updates the Charter in the light of the practices and regulations in effect, particularly with regard to personal health care data, and the recommendations of the French data protection commission. It details the organisation of the two parts of teleradiology (telediagnosis and tele-expertise). In addition, a guide to good practices concerning the quality and safety of teleimaging procedures was published in May 2019 by the HAS. In this guide the HAS makes important clarifications concerning the proper use of “medical imaging examinations with remote interpretation”. It has the particularity of also addressing nuclear telemedicine, deployed with the aim of providing uniform coverage of the country. This guide does not consider mammography, which cannot be done by teleradiology because it necessitates clinical examination of the patient, including palpation. 6.1.2 Dental radiodiagnosis Intra-oral radiography Intra-oral radiography generators, which are usually mounted on an articulated arm, are used to take localised planar images of the teeth (the radiological detector is placed in the patient’s mouth). They operate with low voltage and current and a very short exposure time, of about a few hundredths of a second. This technique is usually associated with a digital system for processing and filing the radiographic image. Panoramic dental radiography Panoramic radiography (orthopantomography) gives a single picture showing both jaws in full, by rotating the radiation generating tube around the patient’s head for a few seconds. Cone-beam computed tomography Cone-beam computed tomography (3D) is developing very rapidly in all areas of dental radiology, due to the exceptional quality of the images produced (spatial resolution of about 100 microns). The trade-off for this better diagnostic performance is that these devices deliver significantly higher doses than in conventional dental radiology. Portable X-ray generating devices ASN and the Dental Radiation Protection Commission (CRD) published an information notice in May 2016 reiterating the rules associated with the possession and utilisation of portable X-ray generating devices. “ The performance of radiological examinations outside a room fitted out for that purpose must remain the exception and be justified by vital medical needs, limited to intraoperative examinations or for patients who cannot be moved. Routine radiology practice in a dental surgery equipped with a compliant facility shall not be carried out using mobile or portable devices ”. This position is consolidated by that adopted by the Heads of the European Radiological protection Competent Authorities – HERCA, for which the use of such devices should be reserved for invalid patients, for the forensic medicine sector and for military personnel in the field of action ( Position Statement on Use of Handheld Portable Dental X‑ray Equipment – HERCA, June 2014). 6.2  Technical layout rules for medical and dental radiodiagnosis facilities Radiology installations A conventional radiological facility usually comprises a generator (high-voltage unit, X-ray tube), associated with a support (the stand) for moving the tube, a control unit and an examination table or chair. Mobile facilities, but which are often used in the same given room, such as the X-ray generators used in operating theatres, are to be considered as fixed facilities. Radiological facilities must be fitted out in accordance with the provisions of ASN technical resolution 2017-DC-0591 of 13 June 2017 mentioned in point 4.2. This decision applies to all medical radiology facilities, including computed tomography and dental radiology. It does not however apply to X-ray generators that are used exclusively for bedside radiography and excluding any use in fluoroscopy mode. A technical report demonstrating conformity of the facility with the requirements of the ASN resolution is to be drawn up by the person or entity responsible for the nuclear activity. 6.3  Radiation protection situation: spotlight on the CT scanner The installed base of 1,245 CT scanners is divided among more than 900 facilities which are covered by an ASN license. Graph 15 shows the distribution of CT scanners by geographical zone covered by the ASN regional divisions, and the distribution of the 185 licenses examined in 2020. In a report published in September 2018, the IRSN notes that the average age of the installed base of CT scanners is higher in the public sector than in the private sector. ASN carried out 30 inspections in 2020. Eighteen inspections focused specifically on sites with CT scanners used to examine patients arriving in the emergency department or for paediatric patients (whether the scanner is dedicated solely to that use or not). One of these 18 inspections was carried out entirely remotely. The purpose of these inspections was to verify the requirements defined in ASN resolution 2019-DC-660 of 15 January 2019 relative to quality assurance in medical imaging. The majority of the centres inspected are in the public sector (11/18). Seven of them have a CT scanner dedicated to the emergency department’s activity. According to the information collected, each scanner performs around 8,000 procedures per year on average. The organisation of the emergency department including access to the CT scanner, particularly in the middle of the night (between midnight and 6 a.m.), is formalised in all the centres. Twelve of the centres have written procedures indicating the patient management actions for patients at risk, while four have verbally communicated procedures and the remaining two have none. Job sheets exist for each medical professional category in 13 of the 18 centres inspected. Fourteen of the 18 centres have trained more than 85% of their medical staff in radiation protection and two have trained between 65% and 85%. The work station qualification pathway remains to be defined, however. A request is normally drawn up for each examination and validated by a radiologist or, in the case of one centre, a teleradiologist. However, no procedures are formalised in writing. 234 ASN Report on the state of nuclear safety and radiation protection in France in 2020 07 – MEDICAL USES OF IONISING RADIATION