 |
In the big picture, radiologic technologists still spend a lot of time capturing x-rays on film, processing film, hanging film. But at the bigger hospitals and imaging center operations that is no longer the case. There, most of the images are generated electronically in a digital format and read on monitors.
In a 2003 survey, the ARRT (American Registry of Radiologic Technologists) found that 55% of technologists queried were involved with digital imaging of some sort, but, of those, 73% said they were working in larger hospitals or health care systems. According to Nance Cavallin, BA, RT(R), a test specialist for the ARRT, of that same group of respondents only 31% said they were involved with a PACS (picture archiving and communications system).
What this boils down to is that the digital evolution in imaging is proceeding but far from finished, which means that technologists are still caught between the old film-based processes and the new digital way.
Quality control is in limbo too. There are no uniform quality control or quality assurance standards for most image processing. The state licensure requirements for technologists vary widely. Quality control protocols on modalities fluctuate from vendor to vendor. The ARRT, which tests and certifies technologists after they have been trained, finds itself in a reactive stance trailing the new technology.
“We are kind of behind the curve to be honest with you,” says Mark Raymond, director of psychometric services for the ARRT. “We try to understand what is going on in the typical practice. If we were ahead of the curve, and our examination focused on cutting-edge things, we would have a high fail rate, because most of our candidates wouldn’t have the experience.”
While there is a digital component to the ARRT’s basic radiographic test that touches on the use of CR (computed radiography) and DR (digital radiography) detectors, by far the bulk of the examination is concerned with traditional x-ray, and all the other things a technologist must know, from patient positioning to administration of contrast media.
Quality control is also addressed in the ARRT tests, but the focus is not a direct one. “Our quality control is integrated with a lot of our outlines—image evaluation, artifacts in images—it’s difficult to quantify it, but it’s central to what we do,” says Sandra Neustel, PhD, an ARRT psychometrician.
The ARRT is still considering whether to add a PACS component to its examinations, says Raymond. And while it has tests for 13 specified competencies, including MR and CT, it has not yet developed a test for PET/CT, although it does allow nuclear medicine technologists to take the CT examination.
NEW BREED, OLD WAYS
Radiographic technologists coming out of school may have a lot of or very little familiarity with digital systems.
“We hired a new graduate last year, and she had never seen DR or CR,” says Roberta Edge, CRA, RT, director of imaging services for the Sutter Gould Medical Foundation in Modesto, Calif. “She caught on quickly, and she’s doing a great job,” Edge adds, “but she had no class prep or a clinical rotation. I think educators are trying to put together what they feel needs to be in a curriculum package, but I would say 80% of the training is still based on film.”
Technologists already employed to work on film-based systems often get their first exposure to digital imaging when their institution makes the conversion. For hospitals and health care systems, this means that, from a quality control perspective especially, training technologists to switch from film to digital imaging has to be handled in-house—and the road for technologists going from film to monitor-based imaging can be a rough one.
“This is such a new frontier,” says Jim Roberts, clinical operations manager of radiology at Dartmouth-Hitchcock Medical Center in Lebanon, NH, “that the vendors are having a hard time providing us with what we feel is necessary in terms of quality control.”
Adds Jerry Bergen, RT, who is Hitchcock’s team leader for the diagnostic radiology section, “What we are going through now is sort of like the Wild West. We are out there alone, trying to define our own standards.”
IMAGE FIRST
From Film to CR and DR |
|
In 1997 the ARRT (American Registry of Radiologic Technologists) initiated testing for a certificate in quality management. According to test specialist Nance Cavallin, BA, RT(R), about 1,000 candidates passed the examination during its initial few years, but the number of candidates has now “leveled off” to about 25 per year. In its handbook for the QM examination, the ARRT lists clinical experience for film and digital x-ray processing that a candidate may use to gain eligibility for certification. For film, they include:
For digital systems, the list is the same except that the requirements are to include evaluating performance of hard-copy printers and inspecting image receptors for cleanliness and environmental conditions. These competencies touch only the surface of quality control in either system, and they do not address digital imaging’s integration with other systems like PACS. Worklists for digital x-ray developed by institutions can be much more specific and comprehensive. Even a task like routinely erasing CR cassettes after usage can be extremely important. If the cassettes sit unused, they can pick up background radiation, which will pollute ensuing patient x-rays. In the move from film to CR or DR, there are a lot more details in the digital systems for the devil to get into. |
| —G. Wiley |
The responsibility of the radiologic technologist is pretty clear. It is a big responsibility too: produce an image that satisfies the radiologist.
“The fact of the matter is, whatever the modality you’re dealing with, you’re still looking at images,” says Cindy Daniels, MS, RT(R), president-elect of ASRT. “It’s the radiographer’s job to evaluate and critique the images.” Daniels is education coordinator for the radiography program at Barnes Jewish College of Nursing and Allied Health, a 4-year college affiliated with Washington University in St Louis.
For Daniels, the RT’s “evaluation” of images would involve checking the positioning of the patient and other patient-based factors, while the “critique” would focus on technique, the use of contrast, and the amount of image detail. “Have I narrowed the field to reduce exposure as well as to improve the image?” Daniels says, for example. “When we look at the images and we see something wrong, we have the educational background and the knowledge to know how to improve or change the image. It’s really not a matter of the system we use, whether it’s film or digital, and CT and MR are in the same bag.”
For film-based systems, a technologist would typically go through a quality control checklist dealing with the film processor to see if it is operating properly, and then with the emerging image; for digital images, the quality control checklist would also assess whether the image (or image set) contains the data the radiologist needs, and whether the image the technologist sees on the modality workstation matches the image that eventually gets delivered to the PACS.
That sounds doable, but for the RT moving from film to digital imaging, quality control can be anything but simple.
CR AND DR
Cathy Parsons, BS, RT, is director of medical imaging for the Cumberland Medical Center, a 200-bed hospital in Crossville, Tenn. This month the hospital is installing DR in one of its x-ray rooms and CR in two others. Parsons is right in the middle of the radiography film-to-digital conversion.
For film processing, Parsons says the big concern has been to make sure the film processor is functioning properly. It is checked daily. Parsons has assigned this task to her lead technologist. “I’m lucky,” she says. “He does it all, and if something is out of range, he will know immediately whether it’s the chemistry or the water flow or whatever it is.” The lead technologist also keeps paperwork on the processor and the other equipment he monitors. “You do have to warm up the equipment [cameras] and make some blind exposures,” Parsons says.
As the Cumberland center moves to CR and DR, Parsons says she is counting on the vendors to help retrain her technologists.
“There will be daily calibrations we’ll have to do to make sure it is not drifting,” she says. “This is something that each technologist will have to do. I feel like we will have to check the digital equipment at least every shift. We have to do that now with CT. If you don’t use the equipment for awhile, you have to do another calibration.”
But Parsons is optimistic that the switch to soft copy will go smoothly. “It won’t be hard to teach the technologists to do the calibrations,” she says. “It will all be computerized, and it will tell you what you need to do.”
NOT SO SMOOTH
For Parsons at her medium-sized hospital, the conversion may go as projected, but at Dartmouth-Hitchcock Medical Center, Jim Roberts and Jerry Bergen say the adoption of CR and DR was anything but smooth.
Dartmouth-Hitchcock is a 400-bed teaching hospital, the only one in the state. It includes a children’s hospital and a large cancer center.
Roberts says the conversion of x-ray to digital involved “a whole new vision of radiology” and that retraining technologists was harder than expected. One reason was that technologists were confused early on about the differences in CR and DR. The DR detectors are stationary and create a higher resolution image using less radiation than required by the CR, which captures images on portable digital cassettes, Bergen says. “The time required in getting the images o PACS is very different,” he adds. “There are many more steps in the CR flow than in the DR flow.”
To clarify the differences, Roberts and Bergen developed a digital imaging skills workbook that laid out for technologists the required procedures for each detection system. It included a work list that they could use to complete the required sequences. Technologists were taught to use speed (S) and exposure index (EI) numbers in addition to the old film milliamperage (MA) and kilovoltage (KV) numbers to adjust image quality. For digital images, the S and EI numbers are the more important ones.
“These are values for a given anatomy part, and there is a range within which that exposure should fall. The images can look acceptable but fall into or out of this range. If it is out of range, some details of anatomy can be missed. That is what we now equate with lightness or darkness,” says Roberts.
“But,” Bergen says, “there are no industry standards to define the EI or S number. It varies from vendor to vendor. If we had a different product line, we would have different numbers. The exposure factors the tech uses are based on technique charts tailored to the exam, the view, and the patient’s size and physical characteristics.”
Adds Roberts, “Some of these factors are automatically set, but the technologist is always able and responsible to make adjustments as necessary.”
INTEGRATION
Even with the quality control work lists and protocols that Hitchcock developed, going to soft copy increased the reliance of the technologist on other system experts.
“Because of interfaces and the flow of images digitally, the technologists depend on other experts, like PACS administrators, to bail them out when there are problems,” says Roberts. “That causes some discomfort for the technologist.” In the old days of film, he adds, technologists were often able to handle camera and processor problems by themselves. Going digital was a whole new ballgame.
Like many bigger hospitals, Hitchcock reacted by creating a team called the Image Quality Assurance Team, or IQAT for short. It is composed of RTs and engineers, including vendor engineers who consult.
“The biggest problem we solved was with the neonatal images,” Bergen says. “That’s what I’m most proud of.”
The film images of the tiny infants were produced life size, which was very small, he says. The digital images were composed of pixels that were automatically enlarged. As a result, any imperfections on the images were magnified. “The neonatal radiologists saw digital imaging as not a positive change,” adds Roberts.
When the IQAT focused on the problem, it was determined to avoid increasing the radiation dose to the infants. “That’s one of the sins of digital imaging: you can improve the image by increasing the radiation dose. We wanted to avoid that at all costs. We came up with new techniques for positioning the equipment around the patient,” Bergen says, noting that the vendor also came up with new processing protocols.
PATIENT DATA TOO
There can be no doubt that conversion to digital imaging places an increased responsibility on the technologist. There are different exposure protocols to deal with and the added responsibility of making sure the images translate from the modality to the PACS, if the institution is using a PACS. There are more people who have to be consulted if something goes wrong. And there is patient data that must be carefully and properly placed into the electronic information stream. This is now true for x-ray; in the sense of integration, it has always been true for CT and MR.
Gerard Durney, MBA, FAHRA, is administrative director of the radiology department at Lenox Hill Hospital in New York City. Durney says that on Manhattan’s Upper East Side he is “surrounded by hundreds of imaging centers.” Lenox Hill therefore has a competitive obligation to make sure that its referring doctors are not only getting good images but that radiologists’ reports accurately reflect patient information.
Durney says Lenox Hill has completed its image acquisition work lists for CR, DR, MR, and CT. Now it is working to turn paperwork like physician requisitions into electronic information. The technologist will be responsible for scanning requisitions into the system, so that radiologists will understand precisely what the referring physician ordered.
“Quality control as a whole is a lot more than we were doing. Before, it was the film and the laser printer, but it wasn’t integrated like it is now,” says Durney.
THE “S” WORD—STANDARDS
In 1992, in response to public demand, Congress passed the Mammography Quality Standards Act (MQSA) setting forth in some detail quality control procedures to be followed for radiographic breast examinations. The MQSA final regulations were issued in 1997.
Now, some experts are calling for similar federal standards for general diagnostic x-ray whether film or digital. Others are opposed to such standards, believing that technologists already have the skills for quality control and that institutions should not be burdened by further regulation.
“I don’t see the need for standards and regulations; that’s our responsibility,” says Sutter Gould Medical Foundation’s Roberta Edge. “That’s why we go to school and what we we take continuing education courses for; that’s what we do for a living, so I do not feel any need for a regulatory body to get involved. My responsibility is to get the best image. If I don’t have that, the radiologists will hold me accountable.”
Edge, who is immediate past president of the American Healthcare Radiology Administrators, says many organizations are involved in setting quality control guidelines for imaging. “The AERS (Association of Educators in Radiological Sciences) is preparing a digital curriculum,” she says.
On the other hand, some educators are calling for standards. Eileen Maloney, MEd, RT(R)(M), is a professor and chairperson of the radiography program at Passaic County Community College in Paterson, NJ. She is a past Board member of the ASRT.
Maloney says the lack of quality control standards is particularly evident for digital radiography. Because the quality control landscape is uneven, she suggests, schools for technologists place less emphasis on teaching quality control than perhaps they should.
“I think most educators at this level teach the material,” she says, “but we don’t expect our recent graduates to do the testing for quality control on a routine basis, because there is always somebody else there to do it, like the supervisor. The students get more training than they did 10 years ago, but they often don’t use it.”
Schools might teach quality control with more effort, if there were standards to teach to, Maloney implies. “The ASRT is promoting federal standards for competence,” she says. “Perhaps general radiography should pattern itself after the MQSA.”
At Dartmouth-Hitchcock where a big effort has gone into developing the IQAT to monitor quality control, there is also a call for standards. “I suspect there will be standards,” says clinical operations manager Jim Roberts. “The industry should set the standard, but the mammography [MQSA] model is a good one to use. As it is now, it’s up to the institution to apply and adjust the old analog systems as best they can to the new digital systems.”
In other words, hospitals and health services are working hard to define quality control as the move is made from film to digital imaging. But there is a lot more work to do.
QA for CT and MR |
|
Quality control for the cross-sectional modalities of MRI and CT is even more involved than for digital imaging with CR and DR. In detailing its quality control standards for MR and CT, the ASRT (American Society of Radiologic Technologists) leaves the “cookbook” details to the specific health care institutions working with specific brands of equipment. The general criteria involve monitoring the performance of the equipment and assessing the quality of images. The use of contrast agents and their effects on patients, if any, are also important factors laid out by ASRT. At Dartmouth-Hitchcock Medical Center, Lebanon, NH, MR and CT technologists are trained from the larger pool of radiologic technologists. They are expected to pass ARRT examinations in their chosen modality when they have sufficient training to do so, according to Jerry Bergen, RT, the center’s diagnostic team leader in radiology. Hitchcock’s clinical operations manager of radiology, Jim Roberts, says the quality control expectations for CT and MR technologists are no different than for x-ray techs. “They are responsible for their images and their studies. We are given feedback by the radiologists within those sections,” he says. For MR, particular care must be given that the patient is carrying no metal, particularly imbedded metal, within the range of the magnet. The metal problem is something that all MR techs must give attention to. At Hitchcock, patients are even asked if they have ever worked around metal such as at a sheet metal plant. “There is a risk that metal may have been projected into an eye and that the patient may not be aware of it,” Roberts says. “In the case of eyes, if there is any suspicion at all, the patient is sent to the diagnostic section for two skull views to identify any residual fragments.” For all modalities, administrators and technologists know they must be careful, because mistakes may end in lawsuits. “A big part of patient safety is just reducing radiation exposure,” says ASRT president-elect Cindy Daniels, MS, RT(R). “That’s the main thing right there, reducing exposure, improving images, and reducing repeats. They all tie together, and with the [level of] litigation now it’s even more important to have a good QC/QA program in place.” The question is whether the programs will continue to be the province of individual institutions as they are now, or whether they will be supplemented by standards for the imaging industry as a whole. |
| —G. Wiley |
George Wiley is a contributing writer for Decisions in Axis Imaging News.
