Dana Thomas, RT(R), is picture archiving and communications system (PACS) administrator at Mobile Infirmary Medical Center, Mobile, Ala, where a Swissray Modulaire direct digital Radiography ddR system was installed in the emergency department in early 2003. The system is heavily used, but is nonetheless reliable. Thomas says, “This unit has been such a workhorse.” He estimates that about 100 patients per day go through the 704-bed hospital’s emergency department. Most of the imaging for those patients is done using the ddR Modulaire, even though the hospital has a second emergency-department radiography room that relies on computed radiography (CR).

“About 98% of studies not done on the Swissray will be portable chest radiographs (where the patient cannot be moved),” Thomas says. “The technologists love the Swissray. Everything is just smoother and quicker.”

Dana Thomas, RT(R)

Thomas, who was instrumental in choosing the ddR Modulaire, says that Swissray’s competitors sometimes criticize the machine’s use of charge-coupleddevice (CCD) detectors to gather images, contending that the CCDs do not provide the image quality of flat-panel detectors. Thomas states that this argument is invalid. He says, “The image receptor is the most expensive part of any system. The Swissray detector is much less expensive. A flat-panel detector costs over $100,000; if it breaks, you have to replace the whole thing. The CCD is less expensive because it is modular. It is designed in pieces, and only one part can fail. The CCD is what we liked about the Swissray.”

As for image quality, Thomas says, CCDs are commonly used for mammography, which is a demanding imaging application. The Swissray produces high-quality images very quickly in the difficult emergency-department setting. Thomas says, “Our radiologists are satisfied. No one else is going to complain about the images if the radiologists do not.”

Christopher G. Ullrich, MD

Christopher G. Ullrich, MD, chief of radiology at the Carolinas Medical Center (CMC), Charlotte, NC, calls the Swissray an elegant technology. He gives the design and functionality of the unit, including the modular CCDs, high marks. CMC is an 800-bed, level 1 trauma center that acts as a hub for three smaller hospitals in Mecklenburg County. The Mecklenburg facilities are part of the Carolinas Healthcare System, the fourth largest health care system in the United States. CMC has two Swissray units in the emergency department/trauma center: a ddRModulaire and a ddR Modulaire Plus. A ddR Modulaire Plus is installed in each of the other Mecklenburg hospital sites. All four hospitals operate as a single radiology service, using one PACS, radiology information system, hospital information system, dictation, and scheduling system, and one radiology group, Charlotte Radiology PA. The CMC emergency department has more than 100,000 patient visits per year. The Mecklenburg hospitals will perform about 415,000 examinations this year.

“People will argue over whether the CCD is as efficient as the flat panel detector,” Ullrich says, “but the CCD has nice characteristics. The image quality has been excellent. These are standard industrial detectors, so the price is low, compared with the custom flat panel approach. We are hoping that the CCDs will be about one-third the cost to repair or replace. The Modulaire Plus is a very flexible device for the technologist to operate. The units have given us no significant trouble to date. The oldest unit has been heavily used for more than a year. “

Ullrich adds, “Swissray is a key component in a much larger strategy.” A big part of that strategy has been to streamline radiology patient throughput. “The productivity has been marvelous, and ddR was central to doing that,” he says.


Because the Swissray uses direct digital capture to produce electronic images and send them to the PACS, the images are available to the radiologists, and to the emergency-department and trauma-center physicians, within seconds of examination completion. Patient placement can be checked for accuracy before the image is ever sent off the machine. If needed, the patient can be repositioned and the image can be retaken. All of this takes just a few seconds. It is an enormous step forward from the days of film processing, and a huge advance from CR and clumsy CR cassettes.

Patients benefit because they can stay in position while image quality is confirmed. Because of the short amount of time between acquiring the image and its receipt by physicians, patients are likely to get better care. Quick turnaround also means that patients in triage face shorter waits. “A trauma patient might need 15 different examinations,” Ullrich says. “We have a limited amount of space in the emergency department. We wanted to leave the analog world. We needed high throughput and high flexibility.”

The trauma-center and emergency-department Swissray units, Ullrich notes, have passed the test. “We think that we are 30% to 50% more efficient with patient throughput. We are probably better than that. With a technologist who knows how to run the Swissray, it is extremely fast.”

Thomas says that not having to handle cassettes is, by itself, a huge time saver. “Consider how much you have to handle a cassette,” he says. “You have to pick it up, get the work list from the computer, identify the cassette, put in the cassette and make sure it is aligned with the tube, shoot the image, put another cassette in, and then carry the first one out. You have to put it in the machine that reads it and wait for the image to come up on the screen. As opposed to pushing a button and seeing your image, it is a lot of difference.”


In an emergency department, patient satisfaction is important. In fact, because patients are encountering unplanned visits and treatments, efficient emergency treatment may win patient loyalty for a hospital where other efficiencies would go unnoticed. Debra McAlear, administrative director for diagnostic imaging at the 210-bed Parrish Medical Center, Titusville, Fla, says, “We put a lot of emphasis on patient satisfaction. After we put the Swissray in use, our patient satisfaction ratings were the highest ever. We came out as the benchmark for the rest of the hospital. By the time the patients are finished, their images have been seen and read.”

At Parrish Medical Center, about 850 patients come through the emergency department each month. The hospital installed a Swissray ddR Combi in a room that serves both emergency and outpatient needs. In addition to the emergency department imaging, the ddR Combi is used for about 1,200 outpatients per month, McAlear says.

Parrish moved into a new hospital in 2002 and laid out the ddR room at that time. It coupled the Swissray ddR Combi with a mini-PACS so that images could be interpreted on workstations. The hospital is just now adding an archive and moving to a full-blown PACS, McAlear says. The ddR Combi was chosen because, she adds, “You can disarticulate the tube arm from the detector. You can leave the patient on the stretcher. You do have to use cassettes in that case, but the patient stays on the stretcher. We wanted that instead of using a portable radiography unit because we would have a shielded room.” A portable unit still is used on those few trauma patients who cannot be taken on a stretcher to the ddR room.


Julie Kendall, RT(R), is technical manager of radiology services for 375-bed Borgess Medical Center, Kalamazoo, Mich. Borgess installed a ddR Modulaire Plus in its emergency department. Soon, it will be installing a Combi Plus in its main radiology suite. “We will have the first Combi Plus in the United States,” Kendall says.

Borgess is also one of the first to get a video camera attachment for its ddR Modulaire Plus that allows the technologist in the control room to view the patient on the monitor during imaging. “We had a very small viewing window in our ED room making it difficult for the technologists to view the patients. To remedy this, Swissray attached a camera to the tube housing so the technologist can look at the patient on the monitor to watch for any patient movement. That has been a big help,” Kendall says.

“Positioning patients has not been an issue,” she adds. “Complete spines are easier than with conventional radiography; hips are a little more difficult, but the images are a lot better. When you image the lower leg, you do have to do it corner to corner.” Kendall says the speed of the Swissray unit has made a big difference. “A spine may take 10 to 15 minutes, depending on how difficult the patient is to position, compared to 30 minutes with conventional imaging. With Swissray, we have the ability to take an exposure, and within seconds have the image appear on the monitor. This literally allows for images to be produced one right after the other.”

Thomas makes a similar point. “You can do almost everything on positioning patients,” he says. “If you are positioning a big, heavy patient, with the images coming up in 5 seconds, you can just let the patient stay there. If the patient needs to be repositioned, you just shoot again. You will not miss the shot with the Swissray.”


McAlear notes that Swissray went out of its way to make sure that technologists were trained properly. She says, “Swissray did a great job. The technologists were used to digital imaging, but you do have to learn the Swissray product. Swissray provided the training, and they have been very responsive when we have had needs.”

Thomas adds, “When we installed the Swissray, we were very busy and short of technologist staff. It was hard to get them down to the sessions and get them trained. We had a few people who were not trained, and Swissray had to come back. They came several times and made sure everybody was trained. They did not charge us for the additional time.”

The same sort of story is told about Swissray’s cooperation in preventive maintenance and repair. “We have an on-site electronics staff,” Kendall says. “Part of our agreement was that one of our people would go to Switzerland for training. He said that it was, by far, the best school he had ever attended. Now, he gets our first call; if he cannot fix it, we will call in Swissray.”

Carolinas Medical Center has a similar in-house approach. “We have our own biomedical technology team, and Swissray has directly trained them,” Ullrich says. “They trained them in the same program they use to train their own service engineers. As a result, we do not have to wait for service. We have had some Swissray people come in for upgrades or modifications, but that is not a routine service situation.”

For trauma and emergency treatment situations, Ullrich says that Swissray has met every goal. “We originally approached this not just as a capital item. We took a hard look at the 5-year cost of ownership. We thought that the value proposition with these systems was really impressive. These systems do not have the cost downside that other systems have, because of the CCD detector.” Ullrich adds, “Would we buy more of them? Yes.”

George Wiley is a contributing writer for Decisions in Axis Imaging News.