LES ACTIVITÉS NUCLÉAIRES : RAYONNEMENTS IONISANTS ET RISQUES POUR LA SANTÉ ET L’ENVIRONNEMENT contractualisation. From now on, the development of teleradiology must be based on a principle of territoriality and subsidiarity, requiring platforms to commit to giving priority to radiologists based in the requesting territory, with an obligation to provide the CNP (G4) annually with the percentage of teleradiology activity performed. As far as the radiologists themselves are concerned, the charter reiterates the ban on any exclusive practice of teleradiology and limits this activity to 20% of annual activity. Finally, the charter sets out detailed contractual arrangements, requiring specific documents relating to medico-organisational governance (such as patient care agreements and the roles and responsibilities of those involved) as well as technical documents (such as contracts covering the provision of equipment and secure networks, or 24/7 maintenance and troubleshooting arrangements). With support from the French Centre of Studies on the Evaluation of Protection in the Nuclear Field (CEPN), ASNR also conducted a study on the use of teleradiology and its effects in order to understand the increase in significant radiation protection events reported in this context. While teleradiology improves access to care and continuity of care, the study highlights a number of weak points in terms of radiation protection when a teleradiology project is not deployed within a controlled framework. Four specific radiation protection challenges were identified: project management; application of the justification principle for examinations, which is undermined by remote practice (lack of access to the electronic patient record and insufficient clinical information being transmitted); inter-professional communication, which may be impaired; and management of the risks associated with this new form of organisation. This study highlights the need for appropriate project management and close consultation between all stakeholders to master these principles, improve communication and limit the occurrence of ESRs. Seven practical improvement measures have been proposed to make this practice safer. The results and recommendations recently published on the ASNR website have been brought to the attention of national stakeholders (see Highlight No. 7). 2.5.1.2 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 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 3D Cone-Beam Computed Tomography (CBCT) is developing very rapidly in all areas of dental radiology, due to the exceptional quality of the images produced (spatial resolution of about 100 micrometres – μm). The trade-off for this better diagnostic performance is that these devices deliver significantly higher doses than in conventional dental radiology. They must be used in accordance with the recommendations given by the HAS in 2009, the conclusions of which indicate that it should only be proposed in certain duly selected clinical indications and reiterate that whatever the case, the fundamental principles of justification and optimisation must be applied. 2.5.2 – Technical layout rules for medical and dental radiodiagnosis facilities Radiology facilities 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 routinely used in the same 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 resolution 2017-DC-0591 of 13 June 2017. This resolution 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 must be drawn up by the RNA. Portable electrical X-ray generating devices ASNR and the Dental Radiation Protection Commission 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). ASNR notes the emergence of mobile radiology services aimed at addressing specific healthcare needs (stroke management, an ageing population, etc.) or the needs of regions affected by medical deserts, although it currently has no clear visibility on how this trend will develop. Consequently, trucks providing dental care circulate in rural areas to relieve congested emergency services (trucks in the Alsace region equipped with MDs capable of responding to emergencies) or to provide care to patients who cannot travel (acquisition of new portable dentistry devices for people in retirement homes, autistic patients, etc.). Experimentation is in progress as part of the ASPHALT project involving the Paris SAMU (Emergency Medical Assistance Service) and nine Paris hospitals, with CT scanners carried in ambulances to treat CVA victims. 2.5.3 – Radiation protection situation in medical and dental radiodiagnosis 2.5.3.1 Computed tomography In France, medical applications represent the primary source of artificial exposure of the public to ionising radiation, chiefly due to CT examinations (see chapter 1). Imaging examinations have proven their benefits for both diagnosis and treatment. The issue at stake however is to avoid examinations that are not really necessary or that offer no real benefit for the patients, or the results of which could be obtained by other available, non-irradiating techniques. In order to control the increase in doses observed over these last few years, two successive dose control plans (see chapter 1) have been developed in recent years. Issued in this context, ASN resolution 2019-DC-660 of 15 January 2019 relative to quality assurance in medical imaging contributes to the control of doses by requiring operational implementation of the justification and optimisation principles. Each year, ASNR conducts about twenty inspections in computed tomography, adopting a graded approach by targeting the Accident & Emergency (A&E) departments (most often shared with the radiology department) and the paediatric CT scanners because of the vulnerability of children. Numerous ESRs occur in CT examinations in the A&E departments and are caused by poor communication or organisation between the A&E staff and 222 ASNR Report on the state of nuclear safety and radiation protection in France in 2025
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