title: Prospective systematic intervention to reduce patient exposure to radiation during pediatric ureteroscopy.
abstract: OBJECTIVE
  After prospective measurement of radiation exposure during pediatric ureteroscopy for urolithiasis, we identified targets for intervention. We sought to systematically reduce radiation exposure during pediatric ureteroscopy.
  
  
  METHODS
  We designed and implemented a pre-fluoroscopy quality checklist for patients undergoing ureteroscopy at our institution as part of a quality improvement initiative. Preoperative patient characteristics, operative factors, fluoroscopy settings and radiation exposure were recorded. Primary outcomes were the entrance skin dose in mGy and midline dose in mGy before and after checklist implementation.
  
  
  RESULTS
  We directly observed 32 consecutive ureteroscopy procedures using the safety checklist, of which 27 were done in pediatric patients who met study inclusion criteria. Outcomes were compared to those in 37 patients from the pre-checklist phase. Pre-checklist and postchecklist groups were similar in patient age, total operative time or patient thickness. The mean entrance skin dose and midline dose were decreased by 88% and 87%, respectively (p <0.01). Significant improvements were noted among the major radiation dose determinants, total fluoroscopy time (reduced by 67%), dose rate setting (appropriately reduced dose setting in 93% vs 51%) and excess skin-to-intensifier distance (reduced by 78%, each p <0.01).
  
  
  CONCLUSIONS
  After systematic evaluation of our practices and implementation of a fluoroscopy quality checklist, there were dramatic decreases in radiation doses to children during ureteroscopy.
authors.affiliation: Division of Urology, Children's Hospital Los Angeles, Los Angeles, California. Electronic address: pkokorowski@yahoo.com.
authors.forename: Paul J
authors.initials: PJ
authors.lastname: Kokorowski
authors.forename: Jeanne S
authors.initials: JS
authors.lastname: Chow
authors.forename: Keith J
authors.initials: KJ
authors.lastname: Strauss
authors.forename: Melanie
authors.initials: M
authors.lastname: Pennison
authors.forename: William
authors.initials: W
authors.lastname: Tan
authors.forename: Bartley
authors.initials: B
authors.lastname: Cilento
authors.forename: Caleb P
authors.initials: CP
authors.lastname: Nelson
mesh_terms: D000293:Adolescent; D004307:Dose-Response Relationship, Radiation; D005260:Female; D005471:Fluoroscopy / Q000009:adverse effects*; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D011446:Prospective Studies; D058996:Quality Improvement; D011832:Radiation Injuries / Q000209:etiology / Q000517:prevention & control*; D018666:Ureteroscopy / Q000009:adverse effects / Q000379:methods*; D052878:Urolithiasis / Q000175:diagnosis*
keywords: ALARA; AP; DAP; ESD; MLD; SSD; URS; anterior to posterior; as low as reasonably achievable; checklist; dose area product; entrance skin dose; kidney; midline absorbed dose; nephrolithiasis; radiation dosage; source-to-skin distance; ureteroscopy