How to establish and use local diagnostic reference levels: an ESR EuroSafe Imaging expert statement

Abstract

Although the Diagnostic Reference Levels (DRLs) have been shown to be an important tool for optimising patient radiation protection, there are still difficulties related to the methodology that should be used to establish and use local DRL values. This statement represents the current view of the EuroSafe Imaging ‘Clinical DRLs’ working group formed with the purpose to produce scientific and educational material on DRLs and promote the concept of local DRLs. Guidelines on how to establish and how to use local DRLs presented herein can be implemented using a multidisciplinary team approach. Local DRLs are easy to determine and implement and they reflect local equipment performance and local clinical needs. They can be updated more frequently than the national DRLs, especially if a dose management system is available. To establish local DRLs, a practical approach could be to collect a reasonable set, i.e., at least 20–30 procedures, of data for well-defined clinical indications and calculate the 3rd quartile values. The median values of the distribution can be set to define the ‘typical values’. The International Commission of Radiological Protection (ICRP) suggests setting ‘typical values’ for newer technologies that enable decreased amounts of radiation exposure for a similar level of image quality. Local DRLs should be similar or lower to the national DRLs. They could be higher only if the clinical benefits for some medical indications are fully explained and reported. Local DRLs may be used as a quality benchmark to track outliers and can be also used as alert values. Key points Guidelines on how to establish and use local DRLs are presented. Local DRLs are easy to determine and implement and can be updated frequently Additionally, local DRLs can be used to track outliers.

Towards the establishment of national diagnostic reference levels for chest x-ray examinations in Sri Lanka: a multi-centric study

“…IDRLs are easy to determine and implement for individual hospitals and reflect institutional practices, equipment performance, and clinical needs [14]. Furthermore, IDRLs can be updated more frequently than local DRLs or NDRLs, allowing for more effective dose optimisation.…”

“…The establishment of institutional DRLs (IDRLs) is considered as the first step towards optimising radiation protection at an institutional level [14]. If radiation doses are consistently exceeded in an institution, the optimisation team, including radiologists, medical physicists, and radiographers, should take appropriate actions to bring doses below what is considered acceptable [15,16].…”

Recommendations for the Screening of Breast Cancer of the Brazilian College of Radiology and Diagnostic Imaging, Brazilian Society of Mastology and Brazilian Federation of Gynecology and Obstetrics Association

“…15,17,18 As the National Health Surveillance Agency (Anvisa) has not established the reference and tolerance levels of the glandular dose for TS in Brazil yet, the recommendation is that each service should carry out a survey of the mean glandular doses using a sample of patients with breasts of different thickness, thereby establishing local reference and tolerance levels. 29,30…”

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“…The use of Diagnostic reference levels (DRL) [1,2] is a first step in an optimization of patient exposure process for medical imaging procedures requiring the use of ionizing radiation [3,4]. DRLs provide an indication of the radiation dose do not exceed for an average-sized patient undergoing a given imaging procedure.…”