Professional Documents
Culture Documents
0 INTRODUCTION:
In our today’s country, radiation protection has turned out to be one of
the most alarming issues in majority of our radiological diagnostic centres.
Though radiography is gaining wide acceptance in nearly all part of the
continent, it is equally important that the radiation protection of staffs and
patients is taken into consideration and this is the sole responsibility of the
radiographer operating the x-ray equipment. For this reason, quality control
was considered one of the tools in optimizing best practice in the area of
radiation protection of both the patient and the staff and also in maintaining
the production of consistently high-quality diagnostic radiographs. (Martin,
2007).
According to ICRP (1991), there are two basic principles of radiological
protection. There are; justification of the practice and optimization of
protection. In the area of optimization of protection, there is considerable
scope for reducing doses to patient without any loss of diagnostic
information, but the extent to which the measures available are used varies
widely. Optimization of radiation protection does not necessarily mean the
reduction of doses to the patient or by operating in the absence of a
demonstrable threshold for stochastic effects but by trade-off between the
benefits of dose reduction and the costs of achieving these reductions. A
number of factors facilitate this trade-off. One of such factors is the quality
control measurements and practices of the department. (Saure and
Hagemann, 1995).
This quality control as noted by Maccia and Moores (1997), involves a
quantitative and qualitative measurements and test of the performance of x-
ray equipments, programs and practices of that diagnostic centre. Hence, in
instituting a good quality control system in our x-ray department, a quality
control program which will monitor the basic components of the imaging
process at a low cost through the use of simple, inexpensive tools and
minimal staff time must be put in place. This quality control will now
determine their adequacy in terms of production of high-quality diagnostic
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radiographs and also evaluates their contribution to all the radiation
protection practices therefore outlining their role in the optimization of the
radiation protection of that centre.
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3.0 AIMS AND OBJECTIVES:
The main aim and objective of this colloquium is to promote awareness
creation about the practical implementation of quality control protocols and
image quality evaluation by consistently implementing simple and
inexpensive actions such as the use of appropriate screen/film combination,
use of secondary radiation grids when necessary, etc.
It also aims to create pools of expertise in the area of radiation
protection of patients, hence alleviating the dangerous practices of
unnecessary irradiation of our patients.
A further objective of this research seminar is to offer assistance and
guidance to an imaging scientist implementing and operating a quality
assurance program any in diagnostic radiology department across the globe.
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Some details which add up to improved cost-effectiveness includes;
a. The number of repeated radiographs is reduced.
b. The rate of flow of patients through the department is improved.
c. The department’s ability to meet the demands made upon its
services is raised.
d. Quality of radiograph produced is higher.
e. Standardization of the radiographic results is achieved and
maintained.
f. The reliability efficiency of automatic processors and of x-ray
equipment is improved.
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All quality control test data should be recorded on standardized forms. It
is suggested by AAPM (1981), that each institution develops its own forms
suitable to its own needs.
1. The use of standardized forms will assure that all of the required data
will be obtained.
2. Forms should be filed as part of the room log.
3. The charting of trend data is a recommended procedure which will
allow easy identifications of variation with time. This is of particular
value in the case of film processors.
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6.0 FACTORS IN OPTIMIZATION OF CONVENTIONAL RADIOGRAPHY
The formation of image of the body involves interplay between many
different factors. To achieve the correct balance between patient dose and
image quality, it is necessary to understand the way in which images are
formed, and to know the factors that influence the image quality and the
radiation dose received by the patient, so that appropriate options can be
selected. These factors include;
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levels to be produce; etc must be put into consideration. (Gray and Winkler,
1983).
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6.2 Exposure Control:
To produce an image on a film with an acceptable level of contrast, the
exposure must be within a relatively narrow range of doses. This is to say
that all exposures must be as low as reasonably achievable. (ICRP Pub. 60,
1990).
Two major factors according to Martin and McKenzie (1993) are
involved in the quantity of radiation produced by the tube. These are; the
tube potential difference (kVp) and the beam filtration. They also noted that,
the exposure factors used will be optimized through the experience of the
radiographers and exposure charts employed for each X-ray unit. The charts
provide a guide to the best factors for different examinations for a patient of
standard build. But however, adjustments will need to be made for patients
of different sizes.
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As noted in IAEA Publication (1995), radiation scatter has adverse
effects on our radiographs which are;
i. Decreases the light transmitting ability of our film.
ii. Decreases slightly the sharpness of the recorded detail.
iii. Increases the random background noise of the film and all these
will result in
iv. a reduction in the contrast of the film.
The amount of scattered radiation can be reduced by means of an anti-
scatter
grid. (Bauer, 1998). The grid consist of a plate containing thin strips of lead
lying perpendicular to the plated surface, which are sandwiched between a
low attenuation inter-space material which are radiolucent materials made of
either aluminium or polyester. X-ray photons are more likely to be attenuated
by the lead strips. (Sandborg and Carisson, 1993).
Secondary radiation grids are not used for examination of the body
parts but only parts intended to produce scatter maybe as s result of
increase in the tube potential difference (kVp).
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6.3 Film Processing:
The final stage in the production of a radiograph is processing the film.
If processing conditions are not optimal, the film will require a higher
radiation dose in order to provide an acceptable film density. Chemicals
should be changed regularly, and the processing conditions, such as
temperature and development time should be carefully optimized. A system
of quality control that involves checking temperatures of processing
chemicals and carrying out sensitometry, involving development of a test
strip of film exposed to a range of light levels ensures optimal performance.
(BIR Pub. 2001). These checks should be carried out daily to monitor
performance in terms of film density, contrast and background fog level. The
performance levels of processors that have a relatively low workload need to
be monitored carefully.
Gray and Winkler (1983) noted that, film processing affects the film
density; therefore, it influences the speed index. Thus, the measurements of
the characteristic curve for a film will also reveal problems with processing. If
a film is taken with optimized processing, it can be considered the reference
standard. Checks can then be made by comparing future results with the
reference standard to identify any deterioration.
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9. Loaded cassette storage.
Determine that loaded cassettes are stored in an area that is properly
shielded from radiation to prevent exposure. They should be stored off
the ground and kept free from dust.
10. Control panel indicators.
Assure all control panel switches, lights, and meters are functioning
correctly.
11. Technique chart.
Make sure a technique chart is available, current, and appropriate for
all procedures normally performed.
12. Patient view ability.
Determine that means are provided to permit continuous observation
of the patient during the x-ray exposure.
13. Exposure switch placement.
Assure the exposure switch is mounted in such a way that exposure
can only be made with the operator in a protected area during the
entire exposure. If unit is portable or mobile without a portable
protective barrier, assure cable on exposure switch provides means for
the operator to be at least nine feet from the tube housing during the
exposure.
14. Lead aprons, gloves, collars, etc.
Assure proper items are available and stored correctly without bends or
folds. If abnormal areas are found, complete procedure 13.
Corrective Action: Missing items from the room should be replaced as soon
as possible. Malfunctioning equipment should be reported to the x-ray
service engineer for repair or replacement as soon as possible.
1. Determine the reason for film repeat as compared to the categories listed
on the data sheet.
2. Record these numbers on the Repeat Analysis Form.
3. Determine the total number of repeated films and the total number of
films exposed. The overall repeat rate is the total of repeated films
divided by the total number of films exposed during the test period.
4. By dividing the number of repeats per category by the total number of
repeated films, a facility can determine the repeat rate per category.
Corrective Action: The percentage of repeats should guide the facility to
focus their efforts to those areas needing the most attention. For example,
films that are too light or too dark may be due to processing problems,
equipment problems that require repair or re-calibration, or technique charts
may need updating.
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3. Follow the chemistry manufacturer guidelines for replacement and
disposal.
4. Record results on the Quarterly QC Checklist.
Corrective Action: If storage conditions exceed manufacturer’s
recommendations, take the necessary steps to resolve the problem.
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7.9 Intensifying Screen Cleaning Procedure:
Objective: To assure that screens and cassettes are free of dust and dirt
particles that may degrade image quality.
Suggested Performance Criteria: Minimize artifacts on films from screens
or cassettes.
Frequency:
1. Quarterly or semiannually (depending on workload and amount of dust in
the environment)
2. When a problem is noticed
Required Equipment:
1. Screen cleaner (as recommended by manufacturer)
2. Lint-free gauze pad or cloth, or camel’s hair brush.
3. Canned air (available from photographic supply store)
Steps:
1. Visually inspect the condition of the intensifying screen.
2. Dust the screen with the camel's hair brush and canned air.*
3. If foreign material (e.g. dirt, developer solution) cannot be readily removed
with the camel's hair brush, use liquid screen cleaner.
4. After cleaning with manufacturer approved cleaners, screens should be
allowed to air-dry, standing vertically, before returning the cassette to use.
5. Record results on the Quarterly QC Checklist.
Corrective Action: If the screen shows signs of cracking, fading, or
discoloration it should be evaluated for replacement.
Assure that the canned air used to clean the screens is "clean" air. If
the air contains moisture, oil, or other contaminants, you may be introducing
artifacts or damaging the screen.
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7.10 Darkroom Integrity or Fog Test:
Objective: To determine and minimize the amount of darkroom fog.
Suggested Performance Criteria: An optical density increase of 0.05 or
less.
Frequency:
1. Semiannually, with each type of film used clinically
2. After bulb or filter replacement
3. After changing or adding types of film
Required Equipment: Includes; opaque material (manila folder), watch or
timer, attenuation block (aluminum step wedge, phantom, acrylic block) to
create a medium, optical density of about 1.0 on the film, densitometer.
Steps:
1. Load a cassette with film and place on a flat surface.
2. Center the attenuation block and expose the film using an x-ray
technique that will result in an optical density of about 1.0 after the
film is processed.
3. With the safelights on, place the exposed film on the work area in the
darkroom. Cover half the film with opaque material, bisecting the
latent image parallel to the long axis of the film.
4. Leave exposed film on the counter for 2 minutes, then process as
usual.
5. While waiting 2 minutes for darkroom fog test, look for any sources of
extraneous light. Any light leaks identified should be repaired as soon
as possible.
6. Inspect the processed film. If there is no discernible delineation
between the shielded and unshielded sides of the film, there is no fog
problem.
7. If a line is evident, measure the optical densities of both sides of the
line with the densitometer. If the density difference is greater than
0.05, corrective action should be taken.
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8. Record results on the Semiannual QC Checklist.
Corrective Action: Repeat the test with the safelight off. If the results
remain the same, the problem may be caused by a light leak or extraneous
light. If the fog level disappears, the fog was due to the safelight and
remedial action must be taken to correct the problem.
Possible Sources Of Darkroom Fog:
- Safelight filters (old or compromised) - Radios
- Safelight housing - Fluorescent light afterglow
- Safelight too close to work area - Light leaks
- Light bulb of incorrect wattage or type - Suspended ceilings
- Ancillary indicator lights on processor - Timers
- Any place there is a hole cut in the wall
- Excessive ambient light through the tinted viewing windows of daylight
loading
systems.
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7.13 Protective Device Integrity Check:
Objective: To assure that the various protective devices such as lead
aprons, gloves, gonadal shields, and thyroid collars provide
optimal protection when positioned appropriately.
Suggested Performance Criteria: No breaks in lead lining of protective
garments.
Frequency: Annually
Required Equipment: Lead aprons, gloves, gonadal, and thyroid shields
Steps:
Option 1: If an image intensified fluoroscopy unit is available, this is the
preferred way to inspect the aprons, gloves, and collars.
1. Lay out the item to be checked on the table.
2. Examine the entire item using the fluoroscope.
3. Record results on the Annual QC Checklist.
Option 2: If an image intensified fluoroscopy unit is not available:
1. Closely inspect each item for kinks and irregularities.
2. Take a radiograph of suspect areas.
3. Process the film and look for breaks in the lead lining.
4. Record results on the Annual QC Checklist
Corrective Action: Any item displaying breaks in the lead lining should be
replaced.
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50 CONCLUSION:
In conclusion, based on patient dose measurements, comparison with
reference values, assessment of image quality, the introduction of quality
control and corrective actions, if needed, and re-evaluation of patient doses
and image quality, has demonstrated its effectiveness for optimization of
radiological protection program.
Finally, a ‘culture’ of regular patient dose measurements, film reject
analysis, and image quality assessment need to become part of diagnostic
radiology.
60 RECOMMENDATION:
From all the information outlined in our colloquium, it has been proven
beyond reasonable doubt that quality control programs and protocols form
an essential part of the optimization process. Therefore, such programs
covering physical and technical parameters associated with the types of x-
ray examination being carried out needs to be instigated in every medical x-
ray facility. For that reason, we strongly recommend that all state radiation
control personnel should be encouraged to promote quality control as a
proven means to reduce doses of exposure, increase and maintain diagnostic
image quality, and limit health care costs.
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REFERENCES:
Bauer, B. (1998), Reference Doses and Quality in Medical Imaging – What the
referring
Practioner and Directing Medical Staff should know: Report EUR 18532
EN; Radiation Protection Dosimetry 80; Pg. 1-3.
Chesney DN., Muriel OC. (1981), Radiographic Imaging: 4th Edition. Pg. 328-
29;
Blackwell Scientific Publications; Boston Melbourne.
Gray JE, Winkler NT, Stears JG, Frank ED. (1983), Technical Aspect of Screen-
Film
Radiography, Film Processing and Quality Control. Aspen System Inc,
Maryland.
Hart D, Wall BF, Shrimpton PC. (2000), Reference Dose and Patient Size in
Paediatric
Radiology: National Radiological Protection Board Report NRPB – R318;
Chitton, UK.
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International Atomic Energy Agency (1995), Radiation Doses in Diagnostic
Radiology
and Methods for Dose Reduction: IAEA – TECDOC – 796; Vienna.
Maccia C, Moores BM, Wall BF. (1997), The 1991 ECE Trial On Quality Criteria
for
Diagnostic Radiographic Images: Detailed Results and Findings; Report
EUR 16635 EN. Office for OfficialPublications of the European
Communities, Luxembourg.
Martin CJ, Darragh CL, McKenzie GA. (1993), Implementation of a Program for
Reduction of Radiographic doses and results achieved through Increase
In tube
potential. British Journal of radiology 66(783): Pg. 228-223.
Martin CJ, Sutton DG, Sharp PF. (1999), Balancing Dose and Imaging Quality:
Appl
Radiat Isot. 50(1); Pg. 13-26.
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McDonald S, Martin Cj, Darragh CL. (1996), Dose-Area product Measurements
in
Pediatric Radiography: British Journal of radiology 66(792); Pg. 1164-78.
Shrimpton PC, Wall BF, Jones DG. (1984), The Measurement of energy
Imparted to
Patients during Diagnostic X-Ray Examination. Using the Dimentor
Exposure – are
product metter;
Suleiman OH, Showalter CK, Gross RE, Bunge RE. (1984), Radiographic Film
Fog In Darkroom: Pg 151:237-238. Neigman’s Unity Press; Toronto, USA.
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