Ideas for Hospitals, Centers, and Practices

Get Ready for Accreditation, Outpatient Centers
A Weighty Issue: Reducing Radiation in Pediatric PET Patients
The Wide View

Get Ready for Accreditation, Outpatient Centers

By now, you probably know that effective January 1, 2012, the Centers for Medicare and Medicaid Services (CMS) will require all outpatient centers offering advanced imaging procedures to be accredited by one of three CMS-selected accrediting organizations: The American College of Radiology (ACR), The Joint Commission, or the Intersocietal Accreditation Commission (IAC).

What you may not have heard is that there is no probation. No accreditation on January 1, 2012, no payments from Medicare. Period.

While it may appear that January 2012 is a long time away, all three accrediting bodies are urging outpatient facility providers of CT, MRI, PET, and nuclear medicine exams to get their accreditation sooner rather than later.

?The planning and the process take time,? said Michael Kulczycki, executive director, Ambulatory Care Accreditation Program at The Joint Commission, in the January/February issue of Axis Imaging News. He continued, ?When 2012 comes and you?re not ready, you?ll lose out on reimbursement.?

The two other accrediting bodies selected by CMS also urged advanced imaging outpatient centers not to delay.

Leonard Lucey, JD, legal counsel and senior director of accreditation, American College of Radiology, Reston, Va, said of the accreditation process, ?If you don?t have any problem, it takes 4 to 6 months. If you have problems, it may take longer. To meet the 2012 deadline, the sooner you get your application in, the better?especially for facilities that have never been accredited before. It?s critical that they get in as quickly as possible. As with anything new, it takes a period of time to get used to the process.?

Sandra L. Katanick, CAE, CEO, Intersocietal Accreditation Commission, Ellicott City, Md, added, ?Starting January 1, 2012, if you are not accredited, you will not be paid. Realistically, they have got to apply by mid July next year in order to even think that they?ll achieve that goal.?

Start the Process Now

To start the ball rolling for your outpatient imaging center, visit the three accrediting agency Web sites:

The American College of Radiology (ACR)
The Joint Commission
The Intersocietal Accreditation Commission (IAC)

Katanick explained that the process can take time because of the many questions and documents that have to be answered and submitted. Aside from the basics, such as qualifications of the staff, physical facilities, and safety records, outpatient centers also have to submit policies and procedures about how the exams are performed. They must submit multiple archived cases, which will be reexamined by the IAC for diagnostic quality and accuracy. Perhaps most significant is a mandatory quality assurance (QA) program. If the program is lax and loosely documented, that will have to be fixed and new protocols implemented.

Lucey commented that it is particularly critical for outpatient centers to pay attention to the directions and instructions of the accrediting agency. Doing so, he said, greatly speeds the process and reduces failure and delays. ?The main reason why people fail is one, they don?t follow directions, and two, they don?t have a physician review the images that are submitted. The images should be the best quality images they have, because we?re asking them to submit examples of their best work. If you can?t pass [our review] on your best work, then you can imagine what the normal routine work is.?

Another reason to follow directions is cost. The accreditation fees not only vary by modality and the accrediting body, but also by the number of reevaluations that have to be performed. Consequently, it will be less painful and less costly to get it right the first time.

?Tor Valenza

A Weighty Issue: Reducing Radiation in Pediatric PET Patients

Although physicians have long been aware of the risks of radiation exposure when imaging pediatric patients, it?s only recently that researchers have been able to hone treatment and technology toward reducing radiation exposure and its corresponding risks to pediatric patients.

Maximum pediatric doses and cancer risks from medical imaging radiation have generally been estimated based on extrapolating adult radiation exposure models and data. Some of the extrapolated protocols are based on weight and size, while others have fixed doses.

While reduced scan times and FDG doses can decrease radiation exposure, they may also provide less than optimal image quality. The challenge has been to make a more accurate adjustment?or combination of adjustments?to PET and PET/CT imaging protocols while maintaining consistent image quality for an accurate diagnosis.

Within the last year, two research teams?one in Seattle and another in Philadelphia?have published separate, new, weight-based protocols for reducing radiation for pediatric PET imaging in the Journal of Nuclear Medicine.

In the fall of 2009, a University of Washington and Seattle Children?s Hospital research team, led by Adam M. Alessio, published ?Weight-Based, Low-Dose Pediatric Whole-Body PET/CT Protocols.?1

Alessio and his colleagues developed new pediatric PET/CT acquisition protocols that were customized to patient weight and then estimated the dosimetry and cancer risk of these low-dose protocols to communicate basic imaging risks.

Eleven patient weight categories for low-dose PET/CT protocols were created, with patients categorized on the basis of the Broselow?Luten color-coded weight scale.

The abstract reports that ?the radiation dose from the proposed protocols is 20%?50% (depending on patient weight), [of] the dose from PET/CT protocols that use a fixed CT technique of 120 mAs and 120 kVp.?

(In addition to the above PET/CT protocol, Alessio created an online ?CT Effective Dose and Cancer Risk Tool? that is for educational purposes only, but can be found at

In conclusion, the Seattle-based team found that their new multiple weight categories protocols can help to minimize radiation dose in pediatric PET/CT procedures while maintaining image quality across the range of pediatric patient sizes.

The second new pediatric protocol comes from a study titled ?Improved Dose Regimen in Pediatric PET? by R. Accorsi, J. Karp, and S. Surti from the Children?s Hospital of Philadelphia and the University of Pennsylvania.2

According to the abstract, the researchers started with literature methods combining phantom with clinical data. These were followed to derive patient-specific noise-equivalent count rate density (NECRD) curves as a function of injected dose.

?From these, it was possible to estimate retrospectively for each patient the scan time that would have been sufficient for the same NECRD as in a 70-kg reference adult; the reduced dose sufficient for constant NECRD and scan time; and a general relationship among scan time, dose, and NECRD. Correlation to the patient statistic giving highest correlation, which was found to be weight, provided rules applicable prospectively.?

The data to create the protocol was derived from 73 patients, whose weights were between 11.5 and 91.4 kg with a mean of 45.4 kg (25 pounds to 200 pounds.)

An algorithm was subsequently created, and the results indicated that utilization of the protocol in PET pediatric studies could produce a constant image quality with time or dose savings of up to 50% for the lightest patients (10?20 kg).

Roberto Accorsi, PhD, former research assistant professor of radiology at Children?s Hospital of Pennsylvania, said in a press release, ?The results of this study show that, due to children?s relatively small size and light weight, it is possible to reduce radiological dose (or scan time) while preserving image quality as compared to PET imaging in adults.?

?T. Valenza


  1. Alessio AM, Kinahan PE, Manchanda V, Ghioni V, Aldape L, Parisi MT. Weight-based, low-dose pediatric whole-body PET/CT protocols. J Nucl Med. 2009;50:1570-1578. Accessed February 15, 2010.
  2. Accorsi R, Karp JS, Surti S. Improved dose regimen in pediatric PET. J Nucl Med. 2010;51:293-300. Accessed February 15, 2010.

The Wide View

Toshiba?s Infinix VF-i vascular x-ray system.

Image quality is everything to a radiologist, especially to interventional radiologists working real time along with support staff in the cardiac catheterization suite. A smaller field of view means that patients have to be shifted, not to mention slowed-down throughput.

To address the need for wider fields of view in interventional suites, Toshiba Medical Systems, Tustin, Calif, has released its latest Infinix VF-i with a new 12? x 12? flat panel detector (FPD) and advanced image processing.

The first installation of Toshiba?s new FPD configuration was at Atlanta?s Piedmont Hospital. This latest version of Toshiba?s Infinix series is actually the fourth installation for Piedmont, but it is the first with the new 12? x 12? FPD with Advanced Image Processing (AIP).

Harry A. Kopelman, MD, director of cardiac electrophysiology laboratories at the Fuqua Heart Center of Atlanta at Piedmont Hospital, said in the Toshiba announcement that the new medium size FPD provides his cardiac interventional team with a better perspective during electrophysiologic procedures than smaller-sized traditional flat panel detectors.

Toshiba reports that the 12? x 12? FPD covers more than twice the anatomical surface area of a traditional cardiac FPD. As a result, it allows interventionalists to increase their working field-of-view and more easily perform procedures outside the heart, while minimally impacting the angulations. Smaller, traditional FPDs can limit the physician?s view, while larger FPDs can cover a wider view, but they can also decrease the angulation options.

Kopelman explained, ?The 12? x 12? panel offers a wider field-of-view, making it easier to image a large cardiac silhouette. It is well suited for cardiac rhythm device implantation and other electrophysiologic procedures.?

?Tor Valenza