Adapted Anatomical Image Criteria

For PA Chest Radiography

DR Muhammad Nadeem’
Mayo Hospital Lahore
BACKGROUND
• Chest Radiograph is the most common
investigation requested by hospital and community
doctors worldwide.

• If taken appropriately it not only informs of

intrapulmonary pathology but can also reveal
abnormalities of the bones, heart and
mediastinum.
“Are we doing the right thing,
in the right way”?
 Standard Criteria (RCR)
1. Performed at full inspiration
2. Symmetrical reproduction of thorax
3. Medial borders of scapulae outside the lung fields.
4. Both apices
5. Whole rib cage above diaphragm
6. Lateral CP angles
7. Retrocardiac lung and mediastinum
8. Spine through heart shadow
9. Image annotations should not obscure the lungs
10.Appropriate collimation of listed structures
 Normal Chest Radiograph fully
complying with Anatomical Criteria
Inadequate inspiration
Scapula & Rotation
Inappropriate collimation and
Overexposure
In our practice we have identified this area as
one that should be subjected to

Audit !
 Objectives

• Improve the quality of patient care

• Promote the effective use of resources

• Enhance the provision and organization of

clinical services
Audit cycle
Two rounds of Audit

METHODOLOGY
 Methodology

-Prospective study involving Two cycles of audit

Performed 4 months apart
By same team of radiologists,
Using an “Audit-Proforma” prepared according to the RCR guidelines.

--Statistical analysis of data was performed using

IBM SPSS 20.0.
Inclusion Criteria:
All consecutive CXR-PA erect performed at
Services Hospital, during two separate 1
month intervals that were 4 months apart.

Exclusion Criteria:
Paediatric and Portable X-rays.
 Proforma for CXR Audit
Retrocardiac
Full Both Rib CP Collimati
Rad # Gender Age Insp. Symmetry Scapulae Apices Cage Angle Lung Spine Annotations on
                   
                   
                   
                   
                   

                   
                   

                   
                   

                   

                   

                   
                   
RESULTS
 Demographic distribution

• The audited chest radiographs

N = 1162
Males ---52 %
Females -- 48 %

• Median Age--- 45yrs

 CRITERIA Compliance Rates
1st Round
Full Inspiration 85%

Symmetrical reproduction of thorax 64%

Scapulae outside lung fields 22%

Visualization of Both Apices 96%

Visualization of Rib Cage 84%

Visualization of CP Angle 90%

Visualization of retrocardiac lung & mediastium 86%

Visualization of Spine 68%

Image Annotations 69%

Appropriate collimation 61%

We had a problem!!!
We tried to solve it!!!

Departmental Meeting

Radiologists Radiographers
 Action Plan
A.Staff were Educated & Encouraged to:
Adopt a lower threshold for checking radiograph adequacy with their senior
colleague.

Rehearse position maneuvers with patients prior to radiography

Pay special attention to patients with special needs.

B. “Immediate feedback”

to radiographers regarding the quality of each Chest radiograph

• 2ND round audit was performed 4 months after
1st audit after implementation of action plan.
 Comparing results of 1st and 2nd rounds of Audit
1st Round 2nd Round Percentage
compliance compliance Improvement
CRITERIA (N=1162) (N=1219)

1.Full Inspiration 85% 92% 7%

2.Centering 64% 78% 14 %

3. Scapulae outside lung fields 22% 39% 17%

4.Visualization of Both Apices 96% 97% 1%
5.Visualization of Rib Cage 84% 93% 9%
6.Visualization of CP Angle 90% 93% 3%
7.Retrocardiac lung and 86% 89% 3%
mediastinum
8.Retrocardiac spine 68% 72% 4%
9.Image Annotation 69% 80 % 11%
10.Appropriate collimation 61% 70% 9%
 Future Strategy

Audit Audit Action

Audit
1 2 Plan 3
Octo Education Marc
May ber Encourage h
2014 ment
N=11 2014 2015
Rehearsing
N N
62 =121
Feedback
=????
CXR
9 CXR CXR

Statistical analysis: IBM SPSS 20.0.

 Conclusion

Key to the perfect radiography are small quality

improvement (QI) projects involving;
1. Regular audits
2. Intradepartmental meetings & planning
3. Multi-disciplinary discussions
4. Education & feedback to radiographers
 References
1)Dr Eugene J Teoh, Dr Sarfraz Nazir, Dr Rachel Benamore, Dr Fiona MacLeod and
updated by CRAC 2015…16 May 2011 Royal College of Radiolgy, UK

2)Audit Cycle published by Irish Medical council ,Requirements for Clinical Audit in
Medical Radiological Practices (Diagnostic Radiology, Radiotherapy and Nuclear
Medicine) Health Service Executive Faculty of Radiologists

3)American College of Radiology. ACR Practice Guideline for the Performance of

Pediatric and Adult Chest Radiography. 2006.

4) European Commission. EUR 16260 – European Guidelines on Quality Criteria for

Diagnostic Radiographic Images. 1996.
Thank You!