Radiation Protection in Digital Radiology Optimisation in CR & DR

Radiation Protection in Digital Radiology
Optimisation in CR & DR
L03
IAEA
International Atomic Energy Agency
Educational Objectives
• Provide rationale for optimisation in Computed

Radiography (CR) and Digital Radiography (DR)
• Describe components of optimisation and specific
methods to detect, correct, and avert errors in CR and
DR
• Identify standards and references for optimisation in CR
and DR
IAEA Radiation Protection in Digital Radiology L03 Optimisation in CR and DR

2
Optimisation includes …
• All activities that ensure consistent, maximum

performance from physician and imaging facility1
• “A distinct series of technical procedures which
ensure the production of a satisfactory product”
• Four steps …
• Acceptance Testing (AT)
• Establishment of baseline performance
• Diagnosis of changes in performance
• Verification of correction of deterioration
National Council on Radiation Protection and Measurements. (1988) Quality

1
Assurance for Diagnostic Imaging, NCRP Report No. 99, Bethesda, MD;
IAEA 3
Radiation Protection in Digital Radiology L03 Optimisation in CR and DR
Optimisation includes both personnel and
equipment
• Identifying aspects of facility operation that require
decisions or actions
• Establishing policies with respect to these
• Encouraging compliance through education and
recognition
• Analyzing records at regular intervals
• Dose optimisation
• Image quality optimisation
IAEA 4
“What’s my motivation?”
• Regulatory Compliance
• International BSS
• National Regulations
• Standards of Care
• Standards established by professional
societies
• Providing the highest quality medical care
• MANAGING RADIATION DOSE!!!
IAEA 5
Factors that affect image quality and patient
dose
Factor Contrast Resolution Noise Patient Dose
Focal spot size X
Off-focus x (x) x
radiation
Beam filtration x X
Voltage (x) x x
X: very important
waveform
connection
kVp X (x) X
x: sometimes
mA (x)
significant
S X
(x): sometimes
noticeable mAs (x) X X
SID X X
Field size X X
Scatter rejection X X
IAEA Wolbarst (1993) Table 19-1 6

Quantifiable Consequences of Degraded
Performance
• Loss of Contrast
Sensitivity
• Decrease in
• Loss of diagnostic accuracy
Sharpness/Spatial
Resolution • Increase in observer
time/fatigue
• Loss of Dynamic
Range • Delay of diagnosis
• Increase in Noise • Increase in patient
radiation dose
• Decrease in System
Speed • Decrease in
efficiency of imaging
• Geometric Distortion operation
• artefacts
IAEA 7
Inherent limitations of human operators
• Every process that depends on a human is a source of random errors
• Every process that automation performs independently is source of
systematic errors.
• Human errors increase exponentially with the complexity of the system
and operator interface.
• It is not a question of whether, but when errors will occur.
IAEA 8
Someone has to reconcile the checking
account
• The technologist/supervisor must
accept responsibility for
appropriate delivery of all images
to the physician.
• Processes must be in place to
verify that all exams performed
and all images acquired reach
their intended destinations (note: an
image count of two does not necessarily
mean both the PA and LAT views!).
• Processes must be in place to
correct errors when detected.
IAEA 9
Some traditional components of optimisation
• QA Committee
• Policies and Procedures
• Reject Analysis
• Radiologist Film Critique
• Operator QC Activities
• Service Events
• Technologist In-service training
• Medical Physicist QC Activities
• Incident investigation/troubleshooting
• Error log maintenance
IAEA 10
Reject Analysis once considered unnecessary
with CR/DR
• Low repeat rates initially reported with DR
• DR is tolerant of incorrect exposure factor selection
• Criteria for improper exposure lacking
• Most DR systems include QC Workstations
• Capacity to modify non-diagnostic images before release
• Bad electronic DR images can disappear without a
trace
IAEA 11
Conventional Reason for Repeated Exam
• Artefacts • Overexposed - too dark

• Mispositioning • Underexposed - too light
• Over-collimation • Marker missing or wrong
• Patient motion • Wrong exam
• Double exposure • Wrong patient
• Inadequate inspiration • Film lost in processor
IAEA 12
CR/DR Reason for Repeated Exam
• Artefacts • Overexposed - high exposure

index
• Mispositioning
• Underexposed - low exposure
• Over-collimation index
• Patient motion • Marker missing or wrong
• Double exposure • Wrong exam
• Inadequate inspiration • Wrong patient
• Lost image
• corrupt data, cannot transfer
• deleted by operator (waste bin)
• Auto-pilot
IAEA 13
How does one perform reject analysis?
• Develop method for capturing rejects

• Collect data
• 3% vs. 12%?
• Analyze data
• Report results to management and staff
• Implement training as indicated
• Share results with vendors
IAEA 14
How can electronic system accommodate
reject analysis?
• Develop codes for Radiologist
exam critique
• QC Techs append critique code
to patient name and modify
Accession number, and Exam
Description (Procedure) Fields
• “None” files archived as usual
• Modified exam routing tables
prevent widespread
dissemination of rejected
images
• “None” files available for review
Some vendors implement reject analysis
IAEA 15
DR systems must be operated properly to
make good images!
• Select the proper examination
• Properly associate demographic
and exam information to image
• Properly manipulate the detector
• Review the image before
releasing
• Know how to recover from errors
without repeating examination
• Follow exposure factor control
limits
• Select appropriate factors for
paediatrics and young adults
IAEA 16
Human operators need to know what is
expected of them.
S U
CRITICAL ELEMENTS
• Vendor applications training is OPERATOR LEVEL
never sufficient. 1 Has knowledge of the following status changes and how to
• Local policies and practice differentiate between them.
a. "WARNING"
must be developed,
communicated, documented, b. "LOCKED"
reinforced, and enforced. c. "ERROR"
• Clinical Competency Criteria 2 Demonstrates ability to differentiate between an error "CODE"

message and a "Service" message
are helpful for standardizing 3 Demonstrates the ability to properly identify the cassette and image
and documenting basic plate location on the displayed pictogram when a jam occurs.
proficiency training. 4 Has knowledge that the [RESET] button should never be pressed by
personnel other that an AGFA service engineer.
• Training must be tailored for 5 Has knowledge of the correct extension to call the PACS Trouble call
technologists, radiologists, line.
clinical engineers, and PACS SUPERVISOR LEVEL
personnel. 6 Demonstrates ability to clear a plate jam in the Upper Section of the
ADC70 by performing the proper sequence of events.
• Radiation protection training of a. Makes sure there are no cassettes protruding through the
referring physicians should also emergency slot.
be considered. b. Properly raises the top cover.
c. Locates and unlocks support rod, and secures top cover into
position with support rod.
d. Properly removes any jammed cassettes or image plates.
IAEA 17
So how do you go about establishing
optimization?
• Define hospital processes from scheduling patient to reporting
diagnosis (workflow analysis)
• Define PACS components and processes that support hospital
processes (IHE references, system architecture)
• For each hospital process, identify operational roles and
responsibilities (task allocation matrix)
• Identify reasonable failure scenarios. Identify single points of failure.
Minimize by redundancy. (failure modes and effects analysis)
• Institute performance measures that indicate when processes are
working and detect, correct, and document errors. Add to the task
allocation matrix.
• Create, document, test, and train downtime and recovery procedures.
• Periodically review and publicize the results of measurements and
adjust as needed.
IAEA 18
Reasons for differences between CR and DR
optimisation
• CR cassette-based vs. integrated
receptor DR
• Cleaning
• Physical defects
• Erasure
• Mis-identified patient, view, orientation
• Need adequate knowledge of
radiographic technique
• Separation between image acquisition
and development
• Time
• Geographic (PACS)
• Distinctions are blurring
• Poorly integrated DR
• Integrated CR
IAEA 19
Consider QC procedures to be a series of
sieves …
Errors RT – Radiography Technologist
Caught by RT before exam
Caught by RT after exam
Caught by Supervisor
Passed on to Radiologist
IAEA 20
Which image is worse?
Reported by radiologist Subsequent image, same machine,

IAEA reported by same radiologist 21
Process map
START
• Flowchart of steps 1. Patient arrives in

imaging department
• Identify potential QC 2. Is exam

N 3. Verify
control points Y
scheduled? exam with
physician
• actions to be taken 5."Arrive" 4. Schedule exam

patient in RIS in RIS
• Identify “work-arounds” 6. Escort patient
• Example: What if RIS is to exam room
out-of-service? QC?
7. Explain exam
to patient
END
• How to continue 8. Select and ID

18. Release patient
operations? QC?
cassettes
17. Complete exam
• Don’t forget actions on 9. Position patient,
cassette, x-ray tube
in RIS
QC?
restoration of service 16. Release images
10. Perform exam
QC? to PACS
11. Scan cassette QC? N

QC?
15. Repeat
12. Preview images necessary?
Y
QC?
QC?
14. Review
13. Repeat
IAEA Y necessary? N
images at QC
22
Step 1. Patient reports for an examination.
• The technologist verifies:
• the patient is the person identified in the exam request
• the anatomy to be examined matches the exam request
• other information about the patient, such as
• Pregnancy
• Restricted motion
• Allergies
• Appliances
• QC accomplished by training or checklist
IAEA 23
Step 2. Technologist identifies the patient and
exam to the imaging system
• Usually occurs before, but
sometimes after the exam is
performed
• Misidentification has consequences
• incorrect information can cause image
unavailability
• incorrect exam info can affect image
development
• mis-association complicates error detection
• proliferation of digital images complicates
correction
• Automation of association =
imperfect QC!
• New classes of errors
IAEA 24
The best image, improperly identified, is
useless.
• Consequences of • Automation of association:
misidentification: • RIS interfaces
• Broken studies • Bar code scanner augmentation
• Orphans • DICOM Modality Worklist
Management (MWL)
• Exceptions • unscheduled exams
• Penalty Box • resource re-allocation
IAEA 25
Step 3. Technologist positions the patient in the
radiation field and performs the examination
• Potential errors
• mispositioning
• patient motion
• incorrect radiographic technique selection
• poor inspiration
• improper collimation
• incorrect alignment of x-ray beam and grid
• wrong exam performed
• double exposure
• QC accomplished at acquisition station?
• Image processing inadequate to correct
• Correction requires repeated exam (s)
IAEA 26
Results:
Rejects during one month
Reason N umb e r %
mispositioned 240 53.3%
artifacts 40 8.9%
test images 22 4.9%
nondiagnostic 20 4.4%
patient motion 14 3.1%
misplaced marker 10 2.2%
no marker 6 1.3%
under-exposed 5 1.1%
inadequate contrast 4 0.9%
over-exposed 2 0.4%
wrong exam 2 0.4%
wrong patient 2 0.4%
T o ta l 450 100.0%
IAEA 27
Step 4. Image receptor captures the
radiographic projection
• Inadequate erasure, lag, ghosting
• Improper compensation for non-uniform gain
• Incorrect gain adjustment
• Incorrect exposure factor selection
• artefacts
• Interference with the projected beam
• Receptor defects
• Interference with converting the captured projection into a digital
image
• Detection possible at acquisition station?
• Correction may require repeated exam
• Can be averted by active QC
IAEA 28
Active QC countermeasures:
emphasize avoiding vs. correcting errors
• Prophylactic erasure at start of shift
• Periodic checks of non-uniformity corrections
• Periodic gain re-calibration
• Technique guide
• Periodic checks of Automatic Exposure Control
(AEC) calibration
• Periodic cleaning of equipment and environment
• Thorough Acceptance Testing of new receptors
• Also incidental to service events and software upgrades
IAEA 29
Step 5. Image receptor renders the captured
projection for viewing
• Incorrect Exposure Field recognition; incorrect
determination of values of interest (VOI)
• Incorrect histogram re-scaling
• Incorrect gray-scale rendition
• Incorrect edge restoration
• Inappropriate noise reduction
• Incorrect reorientation
• QC possible at acquisition station?
• Correction usually possible without repeated exam
IAEA 30
Functions of the QC workstation:
sometimes integrated into acquisition station
• Modify image processing
• Imprint demographic overlays
• Add annotations
• Apply borders or shadow masks
• Flip and rotate
• Increase magnification
• Conjoin images
• Scoliosis
• Full leg
• Modify sequence of views
• Verify exposure indicator
• Select images for archive
• Delete images
IAEA 31
Step 6. Acquisition station transfers the
image to the archive
• Transmission failure
• Image deletion from
local cache
• Information omitted
from transmitted image
• Exposure indicator
• Processing parameters
• Shutters
• Annotations
IAEA 32
Step 7. Digital image is displayed for
viewing by a physician
• Potential errors (hard or soft copy)
• Incorrect GSDF calibration
• Inadequate matrix
• Moire’ (interference) patterns
• Inadequate spatial resolution
• Incorrect or missing demographics or annotations
• Inadequate viewing conditions
• Errors not filtered by previous QC
• QC => Radiologist “Film” critique
IAEA 33
Task Allocation Matrix
Task Responsibility Frequency
Verify Patient ID and exam info Radiographer Each exam
Verify Patient Positioning Radiographer Each view
Verify Image Quality – release or repeat Lead Radiographer Each image
Verify exam in PACS Lead Radiographer Each exam
Reconcile patient data/image counts in PACS Medical Informatics Incidental
Report substandard images Radiologist Incidental
Erase cassette-based image receptors Radiographer Start-of-shift
Test image receptor uniformity Radiographer Weekly
Clean cassette-based image receptors Radiographer Monthly
Compile and review reject analysis data Lead Radiographer Monthly
Verify display calibrations Clinical Engineer Quarterly
Review QC indicators QA Committee Quarterly
Verify receptor calibrations Medical Physicist Semi-Annual
Verify x-ray generator functions Medical Physicist Annual
IAEA 34
Get the radiologists actively involved.
• Key element to any successful optimization program.
• Incidental guidance valuable.
• Radiologist’s Film Critique more valuable.
• Codes transcribed into report
• includes availability and quality items
• documents causes and frequency of substandard imaging; tracks
improvement
• mechanism for establishing responsibility for quality of service
IAEA 35
New accommodations for testing in CR
IAEA 36
Value of automated self-tests
• Some manufacturers provide

automated self-tests
• Should provide operator with
assurance that unit is ready for
clinical use
• Actions should be clearly
indicated by faults
• Should provide longitudinal
information on system
performance
IAEA 37
What do you do with the QC data?
XQi C1 y = -0.0052x + 218.2
• Because systems are

2
R = 0.8897
25
relatively new, 24
23
manufacturers are
MTF @ 2.5 lp/mm

22
21
uncertain about 20
19
longitudinal data 18
17
• Lower limit for test is MTF

16
15
2/13/2002 9/1/2002 3/20/2003 10/6/2003 4/23/2004 11/9/2004 5/28/2005 12/14/2005
@ 2.5 lp/mm = 17% Date
• CsI(Tl) is hygroscopic – A6 QAP data y = -0.0023x + 104.85

2
R = 0.2349
columnar structure is 25
24
degraded 23
Spatial MTF at 2.5 lp/mm

22
• Both systems depicted 21
required detector
20
19
replacement 18
17
16
15
3/20/03 6/28/03 10/6/03 1/14/04 4/23/04 8/1/04 11/9/04 2/17/05 5/28/05 9/5/05
Date
IAEA 38
Commitment to optimisation
• The optimisation effort is integral to how you organize and

perform the work.
• The cost of optimisation is trivial compared to the cost of
inefficiency: consider one bad patient outcome.
• Training for optimisation is professional development for
hospital staff.
• Leverage local resources for optimisation expertise.
• Biomedical engineering
• Medical informatics / Information services
• Medical Physicists
• Hospital QA personnel
IAEA 39
Who is responsible for optimisation?
(“It takes a village …” )
• Physician responsible for clinical service is

ultimately responsible
• Medical Physicist oversees the program
• Radiographer makes day-to-day measurements,
verifies post-repair integrity
• Service engineer carries out repairs, PM,
calibrations
IAEA 40
Answer True or False
• Random error is a source of inherent limitation of

human operators
• It is the responsibility of the physician to ensure
appropriate delivery of all images to PACS
• High doses can go undetected with the use of DR
or CR systems
IAEA 41
Answer True or False
• True. Every process that depends on a human operator

is a source of random errors and every process that
automation performs independently is source of
systematic errors.
• False. The technologist/supervisor is responsible for
appropriate delivery of all images to the PACS
• True. DR and CR have wide latitude and high doses can
go undetected. Optimised exposure parameters should
be used in digital systems.
IAEA 42
References:
Comprehensive
QC Plan for CR
IAEA 43

Radiation Protection in Digital Radiology Optimisation in CR & DR

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Radiation Protection in Digital Radiology

• Provide rationale for optimisation in Computed

IAEA Radiation Protection in Digital Radiology L03 Optimisation in CR and DR

• All activities that ensure consistent, maximum

National Council on Radiation Protection and Measurements. (1988) Quality

IAEA Wolbarst (1993) Table 19-1 6

• Artefacts • Overexposed - too dark

• Artefacts • Overexposed - high exposure

• Develop method for capturing rejects

• Local policies and practice differentiate between them.

reinforced, and enforced. c. "ERROR"

• Clinical Competency Criteria 2 Demonstrates ability to differentiate between an error "CODE"

clinical engineers, and PACS SUPERVISOR LEVEL

be considered. b. Properly raises the top cover.

Caught by RT before exam

Caught by RT after exam

Reported by radiologist Subsequent image, same machine,

• Flowchart of steps 1. Patient arrives in

• Identify potential QC 2. Is exam

• actions to be taken 5."Arrive" 4. Schedule exam

• Identify “work-arounds” 6. Escort patient

• Example: What if RIS is to exam room

• How to continue 8. Select and ID

11. Scan cassette QC? N

• Some manufacturers provide

• Because systems are

MTF @ 2.5 lp/mm

• Lower limit for test is MTF

@ 2.5 lp/mm = 17% Date

• CsI(Tl) is hygroscopic – A6 QAP data y = -0.0023x + 104.85

Spatial MTF at 2.5 lp/mm

• Both systems depicted 21

• The optimisation effort is integral to how you organize and

• Physician responsible for clinical service is

• Random error is a source of inherent limitation of

• True. Every process that depends on a human operator

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