1. Introduction

The advancement of science and technology has resulted in the revolution of the field of medicine. Today, hospitals can make a more accurate diagnosis and prognosis thanks to the electronic devices engineered to test the functionality of the human body. Although this is a significant highlight in the medical field, electronic gadgets are associated with radiation. As such, continuous use may present massive danger to patients as well as the examining medical practitioner. Dose-creep is the seventh most dangerous hospital health hazards. It is a radiation hazard that results from continuous exposure to high levels of radiation. It is a common consequence that arises when the practitioners use more radiation in developing defined imaging for diagnostic radiography. Although there are no immediate threats to the patients’ health, continuous exposure creates a buildup of radiation that may have a long term effect on the patients’ health. Fortunately, as technology continues to advance healthcare providers can easily find remedies to such hazards. Dose-creep occurs as an unpreventable consequence of the transition from film to digital detectors in providing radiography diagnosis. Most digital imaging technology uses ionizing radiation to be able to penetrate within the skin and develop high-resolution imaging. However, massive exposure to higher doses of radiation may lead to the development of cancer among other associated risks. Therefore, medical practitioners are advised to employ the use of the lowest dose possible to achieve the intended diagnostic results. As such, it should be just the right amount of radiation to create a perfect quality diagnostic image.

2. Dose Creep

Dose-creep involves the unintentional exposure of patients to radiation.

2.1 What is Dose Creep?

Dose-creep is a radiation hazard that occurs from accidental exposure of a patient to high levels of radiation. Ionizing radiation is used to provide imaging and medical diagnostic. However, in massive doses radiation puts patients at risk of medical complications. Dose-creep exposes patients to higher level of radiation than intended especially when more precise diagnostics are required (Whitley et al., 2015). Apart from patients, medical practitioners are also at risk to the exposure of radiation when carrying out the examination. Thus, the need for the practitioner to only employ the amount of radiation necessary and recommended by the institution.

2.2. How does creep differ in film radiography and digital radiography?

Film radiography refers to the traditional system of conducting x-rays. It involves the use of photosensitive films. Digital radiography are modern systems that use digital detectors in developing x-ray images

2.2.1. Exposure creep in film radiography

X rays are among the most common techniques of body imaging used by medical institutions to provide diagnostics for internal body complications. X-rays employ the use of films to produce images from dark rooms. Exposure-creep in film-based radiography gradual increases with continuous exposure of the patient to increased radiation dosage. Dose-creep in film radiography is associated with computed radiography and direct radiography (“Dose Creep – Midwest X-Ray, LLC,” 2015). Nonetheless, when the radiation is too high or too low, then the imaging may be unusable due to the lack of precision. As such, it is easier for the radiographer to detect changes in the exposure index by viewing the film.  Film radiography requires optimal exposure to ensure the imaging is comprehensive. One of the essential requirements for the implementation of CR in film radiography is the reduction of the patient’s radiation dose. Eliminating dose creep is critical in producing the right results for film radiography.

2.2.2. Exposure creep in digital radiography

Digital radiography produces better images when radiation exposure is increased. Thus, an increase in dose-creep results in better diagnostics. However, compared to film radiography, digital radiography requires relative lower rates of radiation to produce comprehensive imaging. Nonetheless, most radiographers are bound to increase dosage when carrying out digital radiography to provide better images as well as reduce the noise associated with low levels of radiation (Huda, 2013). However, this creates a considerable risk for both patients and practitioners if continuously repeated over time.

2.2.3. Digital detectors compared to conventional screen-film systems

Most health institutions are transitioning from screen film systems to digital detectors in producing X-ray imaging. Digital detectors are more convenient than screen-film systems. They do not provide as much radiation, and images are developed instantly unlike screen films that take time to process (“Digital Difference: Digital X-rays vs. Traditional X-rays – Maryville Imaging,” 2017). Digital detectors are environmentally friendly and cost-effective, unlike screen films that are expensive and subject to errors.

2.2.4. Methods followed to reduce dose creep in film and digital radiography

These are the techniques that can be employed to minimize dose- creep in both film and digital radiography.

• Hospitals are encouraged to use the newest and advanced technology in carrying out radiography. More modern technology present more heightened detector sensitivity that produces less noise and results in proper image development due to improved detective quantum efficiency (DQE).
• Hospitals should also use modern digital image processors fitted with noise reduction systems that reduce noise, as such, there is no need for increased radiation dose.
• Hospitals are also encouraged to use electronics whose manufacturers have already set a standard Exposure Index value, to regulate radiation.
• They can also use x-ray machines with Automatic Exposure Control (AEC), this allows regulation and constituent application of standard dose.
• Practitioners are also required to follow the ALARA principle (As Low as Reasonably Achievable) as a regulatory measure.

2.3. Cause of dose creep

Dose-creep may be as a result of the human error. Practitioners have the mandate to apply the ALARA principle in using the required amount of radiation. The ALARA principle reduces instances when one may overexpose or underexpose a patient to radiation.

2.3.1. The technological causes of dose creep

Dose-creep majorly results from technological issues. There is not a stipulated technical measure of Exposure Index (EI), as such different manufacturers of X-ray machines provide different standards for exposure index. Some devices offer measures in real time whereas other display measures before the machines are switched on.  Therefore since technologists have a difficult time establishing accurate measures, they cannot determine the appropriate exposure index. This may result in underexposure or overexposure to radiation, especially for digital radiography.

2.3.2. How is the workplace culture related to dose creep?

In most instances, dose-creep is as a result of human error as compared to workplace culture. Hospitals conventionally evaluate radiography competency with image clarity. Low radiation results in the production of duplicate images from the noise produced as the radiations penetrate the object.  Underexposure and blurry imaging results in reprimand (Snaith, 2016). As such, most practitioners would resolve to double the radiation to create clear images. It is common to find radiologist adjust dosage levels to have unobstructed views of the image quality. Unfortunately, this increases medical risks for patients and practitioners from the high exposure to radiation.

2.4. Balancing image quality and radiation risk in radiography

Most hospitals are in the process of transitioning from film radiography to digital radiography. Some few elements of film radiography such as tube voltage and current also apply to digital radiography. Digital radiography, unlike film radiography, offers radiologists with varied options. In digital systems given the imaging parameters are optimized, then the dose can be reduced at the expense of image quality, as image clarity is guaranteed (Engel-Hills, 2006). Digital systems are also fitted with dose monitors and indicators as a means of regulating the amount of dose required for the production of a clear image.

2.4.1. Estimating patient and organ doses

Digital radiography offers useful radiography diagnostics; however, the risks of overexposure to radiation are more significant. There is a need to carry out an estimation of absorbed organ dose and effective dose to ensure the patient is not overexposed to unnecessary radiation. Practitioners must also measure the patient’s weight and height, entrance surface dose (ESD).  ESD increases with an increase in BMI.  Therefore smaller individuals absorb more voltage and radiation as compared to heavy individuals. Organs such as ovaries and testicles are radiosensitive as such increased radiation dosages may have adverse effects on the individual’s health or result in the development of cancer in the radiosensitive regions (Huda, 2013). As such, there is a need to regulate organ dosage.

2.5. Recommendation to lower the dose creep in the radiography field

There is a growing concern on the agenda of medical radiation, with most medical practitioners suggesting the need to lower the levels of administered CT dosages. Dose-creep from radiation exposure is a concern for many patients who do not desire to get much sicker than they were while trying to receive treatment.  The common perception is that most radiographers increase radiation rates to develop image clarity without considering the long term health effects channeled to patients. The higher the radiation the clearer the image, resulting in few complaints from radiologists. Radiologists also increase radiation to avoid noises; however, this is a challenge that can be tackled by adopting the use of advanced technologies (Ma et al., 2013). It is recommended that radiographers lower the dose-creep to protect the patients as well as themselves from the effects of continuous exposure to radiation.

3. Exposure Indicators in DR

Unlike the film radiography where exposure indicators are controlled by exposure factors such as light, image contrast, and density, digital radiography produces clear images despite the inconsistency of exposure factors.  The digital image receptor is one of the essential tools in digital radiography. It assists in maintaining a visual connection with the image. The exposure indicator provides necessary feedback on the type of exposure offered by the image receptor. Over and underexposure results in incorrect reading on exposure indicator. For digital radiography systems, the exposure indicator varies with manufacturing detail. The exposure indicator determines image accuracy (“Understanding Radiology Exposure Indicators – Everything Rad,” 2019). Among the most commonly used exposure indicators are REG, IgM, and S- number among others.  The exposure indicator can also be referred to as the exposure index (EI).

3.1. Exposure index

Digital systems are flexible; however, they present significant risks of overexposure to radiation if not adequately examined. The exposure index provides an indication or measurement of the exposure of radiation reaching the image detector.  Exposure index depends on the image processing technique, exposure to radiation and the type of radiation examination conducted. It is one of the determinants of image quality. Exposure index does not provide the figures on dose but indicates the exposure to radiation supplied to the detector (HealthManagement.org, 2015). Unfortunately, there is no standardized industrial measure of exposure index, as such technologist are bound to make errors. Therefore, there is a need to develop uniformity in the use of radiographic equipment to promote improvements in radiography administration in institutions.

3.2. Target exposure index

Target Exposure Index refers to the amount of radiation passed through an object given the optimum conditions are maintained. The hospital radiology center and the manufacturer of the X-ray machine defines this measure. The values obtained vary according to the procedure and examination did, the organ or part of the body under imaging, and the types of detector used. Target exposure Index ensures that the radiologists apply the ALARA principle.

3.3    Deviation Index

Deviation index is among the measures used to create standard tests of exposure index.  Deviation index similarly provides feedback on radiation exposure to radiologists by measuring noise (Lanca & Silva, 2012). This measure is related to positioning, and movement of the object across the x-ray machine. Deviation Index also quantifies the variation of exposure index to the target index.

4. Conclusion

In as much digital radiography has revolutionized the medical field it present worrying challenges. Radiation presents health risks for both patients and practitioners. Therefore, there is a need for medical institutions to take a keen interest in ensuring that patients do not suffer from increased radiation. Medical practitioners are aware of dangers associated with overexposure to radiation.  As such, they should protect themselves from this radiation. There is a thin line between risking their lives and maintain workplace competence. Increasing radiation may prove them competent, but it creates a health hazard for both them and the patients involved. The practitioners have the duty of ensuring the well-being of their patients at all costs.

References

Dose Creep – Midwest X-Ray, LLC. (2015, December 30). Retrieved from http://midwestxray.net/blog/2015/12/30/dose-creep/

The Digital Difference: Digital X-rays vs. Traditional X-rays – Maryville Imaging. (2017, June 14). Retrieved from https://www.maryvilleimaging.com/blog/50-the-digital-difference-digital-x-rays-vs-traditional-x-rays

Understanding Radiology Exposure Indicators – Everything Rad. (2019, January 3). Retrieved from https://www.carestream.com/blog/2016/09/06/understanding-radiology-exposure-indicators/

Engel-Hills, P. (2006). Radiation protection in medical imaging. Radiography, 12(2), 153-160. doi:10.1016/j.radi.2005.04.008

HealthManagement.org. (2015). Dose Creep: Unnoticed Variations in Diagnostic Radiation Exposures. Retrieved from https://healthmanagement.org/c/healthmanagement/issuearticle/dose-creep-unnoticed-variations-in-diagnostic-radiation-exposures

Huda, W. (2013). A radiation exposure index for CT. Radiation Protection Dosimetry, 157(2), 172-180. doi:10.1093/rpd/nct128

Lanca, L., & Silva, A. (2012). Digital Imaging Systems for Plain Radiography. Berlin, Germany: Springer Science & Business Media.

Ma, W., Hogg, P., Tootell, A., Manning, D., Thomas, N., Kane, T., … Kitching, J. (2013). Anthropomorphic chest phantom imaging – The potential for dose creep in computed radiography. Radiography, 19(3), 207-211. doi:10.1016/j.radi.2013.04.002

Snaith, B. (2016). Evidence based radiography: Is it happening or are we experiencing practice creep and practice drift? Radiography, 22(4), 267-268. doi:10.1016/j.radi.2016.06.004

Whitley, A. S., Jefferson, G., Holmes, K., Sloane, C., Anderson, C., & Hoadley, G. (2015). Clark’s Positioning in Radiography 13E. Boca Raton, FL: CRC Press.

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