BreastScreen ACT Radiography Manual



Contents

1 Contents 2

2 VERSION CONTROL 5

3 RADIOGRAPHY STAFF PROFILE 6

3.1 Radiography Staff Chart 6

3.2 Roles & Responsibilities 6

3.2.1 Screening and Assessing Radiographers 6

3.2.2 Senior (Designated) Radiographer 7

4 CLIENT CARE 9

5 PAIN AND DISCOMFORT 10

6 THE IMAGE PATH 10

7 RADIOGRAPHER’S OBSERVATIONS 12

7.1 Radiographer Detected Clinical Sign 13

8 SCREENING PROTOCOLS for BREASTSCREEN RADIOGRAPHERS 14

8.1 Basic Mammography Technique 14

8.1.1 Overview/Procedure Description 14

8.1.2 Areas of Responsibility 14

8.1.3 Procedure Detail 14

8.2 Fuller Breast Examination Technique (JIGSAW) 19

8.2.1 Overview/Procedure Description 19

8.2.2 Areas of Responsibility 19

8.2.3 Procedure Detail 19

8.3 Screening the Post-Mastectomy Client 23

8.3.1 Overview/Procedure Description 23

8.3.2 Areas of Responsibility 23

8.3.3 Procedure detail 23

8.4 Screening Clients with Silicone/Other Prostheses 23

8.4.1 Overview/Procedure Description 23

8.4.2 Areas of Responsibility 23

8.4.3 Procedure detail 23

8.5 Screening and Pregnancy 27

8.5.1 Overview/Procedure Description 27

8.5.2 Areas of Responsibility 27

8.5.3 Procedure Detail 27

8.6 Screening and the Fainting Client 27

8.6.1 Overview/Procedure Description 27

8.6.2 Areas of responsibility 27

8.6.3 Procedure detail 28

8.7 Screening and the Fitting Client 29

8.7.1 Overview/Procedure Description 29

8.7.2 Areas of Responsibility 29

8.7.3 Procedure Detail 29

8.8 Screening Clients with Physical and/or Intellectual Disabilities 30

8.8.1 Overview/Procedure Description 30

8.8.2 Areas of Responsibility 30

8.8.3 Procedure Detail 30

8.9 Screening and the Lactating Client 31

8.9.1 Overview/Procedure Description 31

8.9.2 Areas of Responsibility 31

8.9.3 Procedure Detail 32

8.10 Declined Clients 32

8.10.1 Overview/Procedure Description 32

8.10.2 Areas of Responsibility 32

8.10.3 Procedure Detail 32

8.11 Incomplete Clients 33

8.11.1 Overview/Procedure Description 33

8.11.2 Areas of Responsibility 33

8.11.3 Procedure Detail 33

8.12 Clients with Implanted Medical Devices (IMD) 33

8.12.1 Overview/Procedure Description 33

8.12.2 Areas of Responsibility 34

8.12.3 Procedure Detail 34

8.13 Technical Repeat Workflow 34

8.14 Clients Presenting with Private Prior Images 34

8.15 Clients who have Attended Another BreastScreening Service 35

8.16 Assessment Clinic Image Protocols 35

8.16.1 Overview/Procedure Description 35

8.16.2 Areas of Responsibility 35

8.16.3 Procedure Detail 35

8.17 Vacuum Assisted Biopsy (VAB) – Tomosynthesis Guided 37

8.17.1 Overview/Procedure Description 37

8.17.2 Areas of Responsibility 37

8.17.3 Procedure Detail 37

8.18 Core Biopsy - Ultrasound Guided 38

8.18.1 Overview/Procedure Description 38

8.18.2 Areas of Responsibility 38

8.18.3 Procedure Detail 38

8.19 Fine Needle Biopsy – Ultrasound Guided 38

8.19.1 Overview/Procedure Description 38

8.19.2 Areas of Responsibility 38

8.19.3 Procedure Detail 38

9 Radiography Technical Quality Program 39

9.1 Quality Assurance (QA) and Quality Control (QC) 39

9.2 Image Reject Analysis (Technical Repeat) 39

9.3 Technical Criteria – PGMI Methodology 40

9.3.1 PGMI (Perfect, Good, Moderate, Inadequate) Image Evaluation 40

9.3.2 Image Quality Assurance 41

9.3.3 PGMI Theory – Practice Standard Methodology 41

9.3.4 PACS Viewing of Images at Time of Reading 41

9.4 Personal Radiation Monitoring (PRM) 41

9.5 Continuing Professional Development (CPD) 42

9.5.1 Overview/Procedure Description 42

9.5.2 Areas of Responsibility 42

9.5.3 Procedure Detail 42

9.6 Certificate of Clinical Proficiency in Mammography (CCPM) 42

9.7 Designated Radiologist feedback 43

10 Equipment 43

10.1 Equipment or Software Failure 43

10.1.1 Maintenance and Fault Logging 43

11 appendices 44

11.1 Appendix 1 – NAS Accreditation Standards, PGMI Evaluation of Clinical Image 44

11.2 Appendix 2 – Outline for Management of Personal Radiation Monitors (PRM) 47

11.3 Appendix 3 – BIS Hints and Tips for Radiographers 2017 V2 48

VERSION CONTROL

|BREASTSCREEN ACT |

|RADIOGRAPHY |

|MANUAL |

|Effective Date: March 2016 |Approval Authority: Executive Director, Cancer, |

| |Ambulatory and Community Health Support |

|Next Review Date: March 2018 |Approval Sponsor: Director, BreastScreen ACT & Senior |

| |Radiographer |

|Last Updated: 22nd March 2017 |Version: 4.0 |

|Version |Effective From |Effective To |Change Summary |

| | | |Creation of New Manual. Content merged from Policy and |

|1.0 |October 2012 |October 2013 |Procedures Manual V 4.3, Updated to new format including |

| | | |revision of content. |

| | | | |

|2.0 |October 2013 |February 2016 |Revised Manual |

| 3.0 | March 2016 | March 2018 |Revision and update of Manual to align with Health |

| | | |Directorate Policy. |

| 4.0 |March 2017 |March 2018 |Revision and update of Manual to align new processes and |

| | | |with new Health Directorate Policy. |

RADIOGRAPHY STAFF PROFILE

1 Radiography Staff Chart

[pic]

2 Roles & Responsibilities

1 Screening and Assessing Radiographers

The Radiographers are the only professional group in contact with all women presenting for screening mammography and therefore pivotal to the success of BreastScreen ACT (BSACT). All Radiographers must be sensitive to the influential nature of their part in the provision of a high quality mammography service at screening and assessment level.

All BreastScreen ACT Radiographers must be eligible for membership to the Australian Institute of Radiography (AIR) and be registered with the Australian Health Practitioners Regulation Agency (AHPRA). They must also hold a current ACT Radiation Licence. All screening Radiographers must hold the AIR Certificate of Clinical Proficiency in Mammography (CCPM) or must complete this Certificate within a reasonable time of commencement.

It is essential that radiographic staff who undertake screening mammography have personal qualities appropriate for this work. These include good communication skills and particular sensitivity to the needs of women presenting for mammography. A working knowledge of the BreastScreen Program and in particular, protocols and new BreastScreen Australia National Accreditation Elements (NAS 1.1) that relate to radiography services are essential. These are NAS 2.5.2 Technical Repeat rate ( latero-medial views are preferred].

Imaging of the larger breast (jigsaws), and

Imaging of prostheses (implants).

1 Cranio Caudal view (CC)

When properly performed the cranio-caudal view includes most of the breast tissue except a portion of the lateral part of the breast. It is a useful view for demonstrating the medial aspect of the breast, but it is important that for good imaging as much as possible of the lateral breast tissue is also included.

In this view, it is most important that the height of the detection plate is correct. The breast should be fully elevated to the limit of its natural mobility and the detection plate placed at the level of the elevated inframammary fold (IMF). An elevated IMF ensures maximum inclusion of posterior tissue and reduces the distance that the compression paddle has to travel over the immobile portion of the breast. This reduces the discomfort caused by ‘pulling’ of the skin and chest wall as compression is applied. If the detection plate is too high, some inferior posterior breast tissue is missed, if too low, superior posterior tissue may be excluded.

The client should stand with feet apart, facing the plate. Always position from the medial side of the client. This allows maximum use of breast mobility in positioning technique. Ensure that her head is turned away from the side being examined. Leaning the client in from the waist over the plate will ensure a forward position. The client may be held in place by one hand gently to her back, the other hand can then gently but firmly position the breast by pulling it forward while ensuring that optimum lateral tissue is included. To reduce the risk of work-place injury, wrists should be kept straight, while elbows are kept close to the body. Compression should be applied slowly with feedback from the client to ensure client’s wellbeing.

The pectoral muscle may be visualised on the posterior aspect of the CC image in 20-25% of women.

Please see 12.1 Appendix 1 for complete detail regarding Image Criteria for the CC view.

Medial tissue should be well visualised and as much as possible of the lateral tissue also.

Aim for inclusion of the pectoral muscle.

The nipple should be in profile.

It may be necessary to perform an extra view of this area if surgery or the natural position does not allow the nipple to be imaged in profile when maximum posterior tissue is included.

There should be no skin folds or shoulder obscuring the lateral breast tissue. A hand on the shoulder as compression is applied will relax the shoulder out of the field of view.

Ideally, the images should be symmetrical to allow ease for Radiologists to report.

2 Medio-Lateral Oblique View (MLO)

Rotate the C-arm 45-60 degrees. The degree of rotation will not be the same for all clients, but is dependent on the angle of the pectoralis major muscle.

The variations in size and shape of breasts are vast and the appropriate angle should be selected for each individual.

The rule is that the detection plate should be parallel to the angle of the pectoral muscle at the mid-axillary line. Observe and select the degree of rotation accordingly. A generalised rule is that taller, leaner women require a steeper angle than shorter women do.

Stand the client approximately 45 degrees and about 10cms away from the detection plate.

The hips should be in line with the lower border of the detection plate and the client should hold the bar which runs down vertically on the C-arm.

Explain the corner of the detection plate may feel uncomfortable in the armpit during the examination.

Utilising the lateral mobility of the breast, use one hand only to lift the breast tissue through and onto the detection plate. Ensure that there are no folds on the lateral side of the breast or in the axilla area.

Check that all the lateral breast tissue is included on the edge of the image receptor and that the infra-mammary angle is well demonstrated.

Walk behind the client and ask if she has any shoulder movement restrictions. Ask her to raise her arm and shoulder, leaning her into the image receptor; place the corner of the image receptor in the posterior aspect of the axilla. Place the client's hand on the C-arm, flexing the elbow so the arm is resting over and onto the back of the detection plate. Encourage the client to have a ‘soft’ hold onto the hand rest.

After ensuring sufficient axillary tissue has been included, return to the front of the client and with the flat of the hand and use a “scooping” action to lift all breast tissue onto the detection plate.

Support the breast with the palm of the hand from the inferior aspect as opposed to “pulling” the breast, with fingers “digging” into the tissue, as this can be quite painful. The breast needs to be lifted up and out so that it will be imaged at 900 to the chest wall.

Gently begin to apply compression, whilst supporting the breast. Tease out any folds in the axillary area. (Hint: A useful hint is to raise the elbow slightly but leave the hand on the C-arm. Raising the hand will cause the pectoral muscle to tense.)

Smooth out the infra-mammary area. If there are twists or folds in the infra-mammary area it may be due to placing your thumb under the breast to “lift” the breast up and out. This can cause an air gap and/or twist in the infra-mammary region. The radiographer may need to ask the client to hold the opposite breast out of the field of view. By lifting the opposite breast up as opposed to “pulling” it back, causes less skin “drag”. Considerable pain can be associated with excessive tension on the woman’s skin, thus lifting the opposite breast “up” as opposed to “away” decreases this “tight” skin tension, allowing ‘loose’ skin along the chest wall to be stretched to an acceptable degree with the compression paddle. Apply compression until the breast is taut.

The top of the compression plate should sit just below the clavicle and the inner edge of the compression plate alongside the sternum to ensure that all the breast tissue is imaged in the medio-lateral oblique view.

Please see 12.1 Appendix 1 for complete detail regarding Image Criteria for the MLO view

During positioning and compression, the Radiographer should be aware of the criteria for the perfect image and strive for optimum results.

Even when correctly positioned the MLO view has a limitation in that it does not include all of the medial breast tissue.

It may be necessary to stretch the axilla across the corner of the detection plate. If uncomfortable, explain to the woman that it is important to include the underarm area for a complete examination. For the perfect MLO image, a full width of pectoral muscle, which extends to the level of the nipple should be visualised.

The nipple should be in profile. However, in some cases due to previous surgery or the natural position of the nipple this may be impossible. An extra view of the nipple area is then required. If the nipple appears to be rotated towards the medial part of the breast once positioned, reposition, checking the lateral part of breast. An inability to apply good compression over the whole breast may indicate inclusion of the latissimus dorsi muscle in this situation. Conversely, the nipple disappearing towards the lateral side of the breast may indicate that not enough lateral breast tissue has been included.

There are two options when positioning the MLO. Once the breast tissue and axilla have been placed on the detection plate, the Radiographer can stand tall by the side of the client and pull the breast tissue up and out and apply compression to the breast. Or the Radiographer can position herself in the lunge position facing the detection plate and pulling the breast tissue up and out and applying compression. Keep wrists in line with forearms and thumb close to forefinger. Elbows should be kept close to the body.

Lunge position: one leg forward with both knees bent and back straight, bottom out to help support the lower back.

3 Lateral (LAT)

This view is sometimes performed at screening if deemed necessary by the Radiographer. It is especially useful for those women, where due to the anatomy, it is impossible to include sufficient pectoral muscle as well as the inframammary region on the medio-lateral oblique view.

In imaging prostheses, a lateral view may be performed to ensure inclusion of as much tissue as possible.

In the Assessment Clinic, a lateral view may be used for lesion localisation.

The nipple must be in profile. The inframammary area should be well visualised. A short wedge of pectoral muscle should be visible at the chest wall edge of the image. The breast tissue should be well compressed and lifted up and out at 90° to the chest wall.

4 Latero-Medial Lateral View (LAT)

The tube is rotated 90 degrees and the top edge of the detection plate is placed at the level of the sternal notch. The chin is extended over the top of the detection plate and the sternum is placed against the plate edge so all the breast tissue can be included.

The arm of the side being examined is lifted up and across to hold the C-arm handle. The elbow is flexed to relax the pectoral muscle.

The whole breast is supported in the palm of the hand and lifted upwards and outwards from the chest wall.

The woman is rotated slightly forward until the nipple is in profile, and the compression is gradually applied to include the inframammary area and as much of the pectoral muscle as possible.

5 Medial -Latero Oblique View (Reverse Oblique)

Similiar to positioning for the 90-degrees lateral medial but with the C arm angled from superior lateral to inferior medial.

Used when standard MLO cannot be obtained, e.g. for women with:

disabilities (e.g. in a wheelchair)

a prominent sternum

a prominent pace-maker

recent open-heart surgery

a prominent pectoral muscle

better demonstrates medial tissue and

upper border of film-holder should be at level of supra-sternal notch

6 Posterior Nipple Line

An important method of image evaluation is to use the posterior nipple line PNL rule or 1cm rule. This is not an anatomical structure of the woman or breast but a landmark which is representative of the alignment of the nipple to the chest wall.

The PNL will vary with age as the younger woman’s PNL will be almost perpendicular to the chest wall. With age and atrophy of the breasts supportive structures, the breast will tend to soften and fall, altering the PNL to a steeper downward slope.

Despite the variation sometimes seen with age, the PNL is a valuable tool in evaluating the CC and MLO images.

The PNL is measured on the images to ensure adequate tissue has been displayed.

1. 2.

The PNL on the MLO view The PNL on the CC image

Source: Shirley M. Long. “The Handbook of Mammography”, 4th Edition

(Mammography Consulting Services).

Adequate tissue is considered imaged when the CC measurement is within 1cm of the MLO measurement.

MLO view: The PNL is measured from the nipple back to the anterior border of the pectoralis muscle, or to the edge of the film if it strikes first, forming a 90 degree angle with the pectoralis muscle. A linear measurement is recorded.

CC view: The PNL is measured from the nipple to the edge of the film, regardless of whether pectoralis muscle is imaged or not.

Measurements of the MLO and CC view are compared. Adequate tissue has been displayed if the CC measurement is within 1cm of the MLO measurement.

3. 4.

The PNL is elevated correctly for the MLO projection (diagram 3 above). Depending on breast size and weight, it is often difficult to elevate the breast; therefore the PNL slopes down more steeply (diagram 4 above).

Source: Shirley M. Long. “The Handbook of Mammography”, 4th Edition

(Mammography Consulting Services).

2 Fuller Breast Examination Technique (JIGSAW)

1 Overview/Procedure Description

Women with larger breasts often require more than one film in each projection in order to demonstrate each breast fully. A ‘Jigsaw’ technique is required to ensure full breast tissue is covered and visualised in the images. It is important to use the image size to its maximum potential for each section positioned.

2 Areas of Responsibility

All Radiography staff.

3 Procedure Detail

It is necessary to judge how many images will be required and mentally divide the areas of breast tissue to be imaged.

Realistically there must be a degree of overlap from image to image to ensure that no area of breast tissue is missed.

It is essential that each breast is imaged with the same jigsaw combination so that the images can be viewed accurately. As many as 16 films may be required for one examination. With larger breasts, it can be difficult to minimise the skin folds but it is essential to persist as lesions may be missed when obscured by folds.

1 CRANIO CAUDAL VIEW (CC)

Positioning technique is the same for the basic mammography cranio-caudal positioning, however the breast is divided into sections with each section imaged separately.

Three CC images may be performed on women with large breasts:

Lateral aspect

Medial aspect

Nipple and anterior aspect

Any combination of these 3 views may be required.

When positioning for the inner and outer areas of the breast, check there no folds (or at least the minimum amount possible) underneath the visualised breast tissue and that the breast does not appear to be overlapping underneath.

1 “1” view

This position images the lateral section of the breast.

The breast is lifted to maximum elevation and the breast plate placed at the level of the inframammary angle.

Place the breast onto the detection plate ensuring the lateral section will be imaged.

Using the flat of the hand, or two hands if preferred, lift the breast onto the detection plate, ensuring no folds are underneath the breast.

Hold the breast firmly and pulling lateral tissue around gently while lower the compression paddle.

2 “2” view

This position images the medial section of the breast.

The detection plate is not altered in height from the “1” view.

Align the breast onto the breast support ensuring the medial section will be imaged.

Using the flat of the hand or two hands if desired, lift the breast onto the breast plate, ensuring there are no skin folds underneath.

Holding the breast firmly, gently compress. It may be necessary to ask the client to hold the opposite breast up and away so that is does not obscure the resulting image. This also assists to smooth out medial folds.

3 “3” view

This position is for the anterior section of the breast.

The breast support height is not altered from the previous views.

Lift the breast onto the breast support, ensuring the anterior portion will be imaged. The client may need to stand slightly back from the breast plate so the tissue does not extend too far forward over the image edge.

Compression is applied gently, the area behind and around the nipple can be tender on compression.

If a 3 view is required to image only a small area of tissue, it is advisable to still include a reasonable amount of tissue regardless of the overlap from 2 view because the anterior part of the breast is particularly sensitive when compression is applied.

It is important to ensure that there is a section of overlap on all images to ensure the breast has been imaged adequately.

2 MEDIO-LATERAL VIEW (MLO)

Positioning technique is the same for the basic mammography medio-lateral positioning, however the breast is divided into sections with each section imaged separately.

Three MLO images may be performed on women with large breasts:

A. Axillary area with breast left to rest on the detection plate.

B. Inframammary and lower breast area (with the breast lifted up and out).

C. Nipple and anterior portion of breast.

Any combination of these 3 views may be required.

When positioning for the upper or lower areas of the breast, check there no folds (or at least the minimum amount possible) underneath the visualised breast tissue from below or above and that the breast does not appear to be “drooping”.

1 “A” view

Position as for the medio-lateral view discussed but focus on the upper area of the breast tissue, i.e. axillary area.

If the breast is heavy/large, sometimes it is wise not to lift the breast up and out at 90 degrees to the chest wall as you may incur a fold in the axilla.

Tuck the abdomen back to ensure it is not being compressed.

The client may need to hold the opposite breast out of the field of view.

2 “B” view

The focus for this image is on the lower section of the breast i.e. the inframammary area.

The breast support is not altered in height from the “A” view. Instead, the arm is left either resting loosely on the c-arm or placed behind the plate by the client’s side.

This allows for the lower section of the breast to be lifted away from the chest wall at 90 degrees and onto the plate.

The inframammary area should be well displayed and often the tissue in this area needs to be smoothed out medially.

Any excess abdominal skin needs to be tucked behind the plate and away from the field of view.

The client may need to hold the opposite breast out of the field of view.

3 “C” view

This image shows only the anterior aspect of the breast nipple area.

The breast support height and angle remain the same as for the A & B views.

The arm can be left by the side, raising it onto the breast support and holding the c-arm can create folds.

The breast is lifted up and away from the chest wall at 90 degrees, but only the anterior portion of the breast is placed onto the breast support.

Compression is applied gently, with the Radiographer being aware that the area of breast behind and around the nipple can be very painful when compression is applied.

If the C view is required for only a small area of tissue it is advisable to include a reasonable amount of tissue since compression of a small area of tissue can be painful. Ensure the nipple is in perfect profile in these images.

It is imperative there is a section of overlap on all images as to ensure all breast tissue has been imaged adequately.

3 Jigsaws of clients requiring more than 12 images

Occasionally Radiographers may be required to take more than 12 images to image the larger client. In this situation the Radiographer must use her discretion, ensuring an adequate number of images are taken to image the entire breast tissue. Additional images usually required are detailed below.

1 Cranio-caudal

“1.3” view – similar to a “3” view position, but focus on the lateral, anterior aspect of the breast.

“2.3’ view – similar to a “3” view position, but focus on the medial, anterior aspect of the breast.

2 Medio-lateral oblique

“A.C” view – similar to a “C” view position, but focus on the upper, anterior aspect of the breast.

“B.C” view – similar to a “C” view position, but focus on the lower, anterior aspect of the breast.

3 Screening the Post-Mastectomy Client

1 Overview/Procedure Description

To ensure clients are appropriately screened.

2 Areas of Responsibility

All Radiography staff.

3 Procedure detail

Standard CC and MLO views are obtained of the remaining breast. Imaging of the affected side is not required.

If further detail is required, please also refer to the Clinical Services Manual located in: Q:\CH\CY&W\BScreen\Policies and Procedures

4 Screening Clients with Silicone/Other Prostheses

1 Overview/Procedure Description

To ensure the mammography examination demonstrates the maximum amount of breast tissue in clients with augmented breasts.

All women with breast implants attending for screening will be advised via the implant consent form, prior to screening, that the integrity and contour of the implant will not be reported or noted by the screening program. If the woman consents for the mammogram the screening will proceed to completion. The images will be screen read by the radiologists in the normal manner and no comment will be noted by the radiographers or radiologists regarding possible implant rupture or leak.

If the woman experiences unexpected significant pain as the screening images are being performed, the procedure should be terminated, screening declined and the woman asked to see her GP for follow-up.

If further detail is required, please also refer to the Clinical Services Manual located in: Q:\CH\CY&W\BScreen\Policies and Procedures

2 Areas of Responsibility

All Radiography staff.

3 Procedure detail

Clients who have had augmentation mammoplasty are eligible for screening. Extra time is allocated for these clients as more images are required to cover all breast tissue.

The amount of compression used will be tailored to each individual client. A balance is always sought between image quality, client comfort and tolerance. Overall, less compression is used when imaging implants in comparison to non-implant clients.

There are two major locations for placement of the implant relative to the breast tissue:-

Retro-pectoral

Pre-pectoral

1 Retro-pectoral Implants

In clients with retro-pectoral implants the implant material does not obscure the majority of the breast tissue and the routine views can be performed. Eklund is chosen for tissue type exposure. If the breast is not adequately compressed a CC ‘3’ and a MLO ‘C’ view are required. The lateral view is not performed.

1 Cranio-caudal view (with implant in view)

The client is positioned as for a cranio-caudal projection on a client with no breast augmentation. However, limited compression is applied to the breast because the implant will be imaged in this view. Selection of the correct exposure algorithm on the modality is required.

Implant in view -> the implant is compressed with the implant in the field of view. When the entire breast is imaged, including the implant, limited compression is applied.

Source: Shirley M. Long. “The Handbook of Mammography”, 4th Edition

(Mammography Consulting Services).

2 Medio-lateral Oblique view (with implant in view)

The client is positioned as for a medio-lateral projection on a client with no breast augmentation. However, limited compression is applied to the breast because the implant will be imaged in this view. Due to limited compression the breast may not be lifted up and out as would normally aim for in the non-augmented breast. Selection of the correct exposure algorithm on the modality is required.

3 Pre-pectoral Implants

Pre-pectoral implant material can obscure significant amounts of breast tissue.

Projections taken with the implant in place require about half the normal compression. The compression plate is applied in order for the implant to be held in place while the exposure is taken. Most of the breast tissue will not be well visualised, except for the part around the implant. Both MLO’s and CC’s are taken as per described in the information under Retro-pectoral Implants CC (with implant in view) and MLO (with implant in view). In addition to these views, the following ‘pushback’ views are also performed. Lateral and IMA views are performed at the discretion of the screening radiographer.

4 pushback views (no implant in view)

The implant can be pushed back and away from the breast tissue. A total of 4 views for each breast are required for a complete examination.

Cranio-caudal “push back” view –> with a medial and lateral bias respectively.

Medio-lateral oblique “push back” –> with an upper and lower bias respectively.

The routine four views are taken with the implant out of view as much as positional possible together with an extra four “pinch” views where the implant is pushed back out of the field and only the breast tissue in front of the implant is x-rayed (Eklund technique).

“Pushback” technique -> the implant is gently displaced back as the anterior tissue is brought forward and compressed. Normal compression can be used on these views because the implant has been excluded from the compressed tissue.

Source: Shirley M. Long. “The Handbook of Mammography”, 4th Edition

(Mammography Consulting Services).

5 Cranio-caudal push back technique (no implant in view)

Place the detection plate the same height or slightly higher than that for the cranio-caudal view which imaged the implant.

Hold the breast to be imaged with the fingers of both hands at the anterior margin of the breast i.e. near the nipple.

Gently work your fingers back toward the chest wall, pushing the implant posteriorly and “pinching” breast tissue between your fingers.

Alternatively some of the taller Radiographers may prefer to hold the breast with both hands near the chest wall, “pulling” as much tissue as possible forward over the implant, hence easing the implant posteriorly.

Once the breast tissue has been brought forward, still holding the tissue, lean the client forward placing the implant on the edge of the detection plate and the anterior tissue onto the detection plate itself.

Repeat this process, one with a lateral bias, the other with a medial bias overlapping at the nipple/areolar area.

Gradually apply compression, easing the compression paddle past the anterior surface of the implant.

Normal compression is applied.

Selection of the correct Eklund exposure algorithm on modality is required.

6 Latero-medial pushback technique (no implant in view)

Rotate the C-arm detector plate, to the appropriate angle for the client (same angle as that used for medio- lateral oblique with the implant being imaged)

Position client standing slightly back from the detection plate

With the fingers of both hands, starting at the anterior margin of the breast i.e. near nipple, gradually work your fingers posteriorly, pushing the implant posteriorly and holding the breast tissue between your fingers

Alternatively, the taller Radiographers may hold the breast near the chest wall, with both hands feel for the implant, working fingers forward, gently displacing as much tissue as possible over the implant. This displaces the implant posteriorly.

Once the breast tissue has been brought forward, still holding the tissue, lean the client toward the detection plate until the implant is located at the edge of the detection plate and the anterior displaced tissue is resting flat on the detection plate surface.

Gradually apply compression, easing the compression paddle past the anterior implant surface to rest on the breast tissue. Make certain breast tissue from axilla to post areolar is compressed.

The client should lean against the compression paddle to keep the implant back and to keep as much breast tissue as possible forward

Normal compression is applied

Selection of the correct Eklund exposure algorithm on modality is required

7 Inframammary angle (IMA)

‘Pinch’ breast tissue back. Change compression paddle to a ‘spot’ compression plate and lower paddle over IMA tissue. The image will appear magnified.

OR

If IMA positioning not possible, zoom the MLO with implant views to demonstrate this area

8 Breast Implant Rupture

BSACT does not report or comments on possible breast implant rupture because mammography is not a definitive diagnostic tool in such cases. Ultrasound, CT and MRI are recommended procedures to detect implant rupture.

If further detail is required, please also refer to the Clinical Services Manual located in:

Q:\CH\CY&W\BScreen\Policies and Procedures

If further detail is required, please also refer to the Radiology Services section within the Clinical Services Manual located in: Q:\CH\CY&W\BScreen\Policies and Procedures

5 Screening and Pregnancy

1 Overview/Procedure Description

It is inadvisable for clients who are pregnant to be screened. For most clients in the program, this is not an issue but occasionally clients volunteer this information or are still within the pregnancy age range when they attend their screening visit.

If greater detail is required, please also refer to the Clinical Services Manual located in:

Q:\CH\CY&W\BScreen\Policies and Procedures

2 Areas of Responsibility

All radiography staff.

3 Procedure Detail

All clients under the age of 50 years old are asked their pregnancy status and the radiographer is to update the comments section on the BIS ‘mam’ screen documentation as such. Although Radiation Physicists believes there is negligible risk to the foetus with mammography, all women who fall under the age of 50 are asked their pregnancy status prior to the mammogram taking place. Clients who confirmed or are unsure of their pregnancy status will be declined on the day and advised to discuss their requirements with their treating medical practitioner. If the client is declined, please follow section of this document 8.11 Declined Clients.

6 Screening and the Fainting Client

1 Overview/Procedure Description

Management of BSACT recognises its duty of care to their clients regarding all aspects of client/consumer safety.

The following guidelines relate to management of women who faint or collapse in BSACT clinics.

2 Areas of responsibility

Civic clinic -> staff responsible may include but are not limited to the rostered radiographer/s, the Medical Officer and nurse counsellor/s.

Phillip and Belconnen clinics-> staff responsible may include but are not limited to the rostered radiographer/s and the administration reception staff.

3 Procedure detail

1 If the client is unconscious for extended period of time

ALERT

ONE BSACT CLINICAL STAFF MEMBER IS TO REMAIN WITH THE WOMAN UNTIL SHE HAS RECOVERED AND/OR HAS BEEN TAKEN TO A HOSPITAL BY AMBULANCE

Call an ambulance (000).

Seek assistance from clinical staff who are rostered on the day.

Notify the Medical Officer and Senior Radiographer as soon as practicable.

Notify Director of BSACT as soon as practicable.

Complete an Incident report form on ACT Health’s Riskman database.

All staff involved in attending to the client must write a BIS progress note with all relevant information pre and post the fainting episode INCLUDING the Riskman database reference number (if known at the time when completing the BIS note).

2 If the client is feeling faint but is conscious

ALERT

ONE BSACT CLINICAL STAFF MEMBER IS TO REMAIN WITH THE WOMAN

UNTIL SHE HAS RECOVERED

Encourage the woman to lie down with her legs elevated.

If the client prefers to sit, she should lower her head towards her knees.

Apply a cold compress and/or a glass of water may be offered.

Observe and reassure the client for approximately 10 minutes.

Notify the client’s Next of Kin /Carer if present.

Loosen any tight clothing.

Ensure fresh flow of air.

Give oxygen via Oxyviva if necessary.

Check for any injuries sustained if the client has fallen.

After recovery, observe and reassure the client for 10 minutes.

Offer a ‘jelly-bean’ and/or a cup of tea or cold water and/or a biscuit.

Contact Medical Officer, Nurse Counsellor and Senior Radiographer to inform them of the incident and its outcome incident.

Complete an Incident report form on ACT Health’s Riskman database.

All staff involved in attending to the client must write a BIS progress note with all relevant information pre the fainting episode INCLUDING the Riskman database reference number (if known at the time when completing the BIS note).

1 Clinical Coordinator

Provide clinical advice to staff/client as required.

Follow-up clinically with client/General Practitioner as required.

Update BIS progress note including the Riskman reference number.

2 Senior Radiographer

Include the incident in summary report for monthly Clinical Team Meeting.

If a client states that she feels faint, or is prone to fainting before the examination begins, try to ascertain the reason why (e.g. fainted previously from a painful examination, low blood pressure, feels ill, too hot/cold, has not eaten recently etc.). Try and eliminate the cause (anxiety, pain, change air temp etc) and ask if she would like to postpone the examination until she feels better.

If a client faints during the mammogram, stop immediately, decompress the paddle and either assist the client to the chair or allow the client to slide to the floor. The radiographer should not try and break the fall, or take the client’s weight, or position herself in such a way that she could be injured herself. Place the client in the recovery position and either call or press the emergency alert button for assistance. Once the client has recovered, continuation of the screening will be at the discretion of the client and the radiographer. The radiographer may seek assistance if there is an appropriate person available.

7 Screening and the Fitting Client

1 Overview/Procedure Description

In very rare circumstances, a client may fit before, during or after her screening appointment at the clinic location. Do not attempt to restrain a client who is the fitting.

2 Areas of Responsibility

All Radiography staff.

3 Procedure Detail

After fitting has subsided, place the client in the recovery position. Call for clinical assistance and follow best practice to ensure the client is well enough to leave the clinic. Continuation of the screening will be at the discretion of the client and the radiographer. The radiographer must complete a BIS progress note and enter an incident in the ACT Health Riskman database and notify the Senior Radiographer.

8 Screening Clients with Physical and/or Intellectual Disabilities

1 Overview/Procedure Description

Special attention must be paid to a client presenting with a physical/and or intellectual disability as the disability may affect their ability to participate in the screening program.

2 Areas of Responsibility

Client support administration staff and a Radiographer (or Senior Radiographer) at the time of making the appointment. All radiography staff at the screening appointment.

3 Procedure Detail

1 Clients with a Physical Disability

The radiographers are to perform the screening mammogram within the physical limitations of the client and the equipment being used. It is at the discretion of the client and the radiographer as to ascertain that at any time, the screening mammogram may be impossible or in fact, considered inappropriate to be continued due to the expressed discomfort of the client regarding the positioning required by the radiographer to perform and/or the radiographer is placing herself at risk regarding acquiring a physical injury herself while trying to position the client. The radiographer will be mindful regarding the positioning needed and ensure continued consent (if deemed appropriate to do so) is sought throughout the screening episode. The radiographer must also be mindful of one’s risk of personal injury while attempting the mammogram.

If deemed appropriate, the radiographer is to:

discuss future management options with the client which should include uncertainty over the Program’s future suitability for the client regarding management of her breast health

create a BIS ‘Attention Medical Officer’ note stating all the details regarding the attended appointment and conversation had between client and radiographer regarding the experience of the mammogram

Clients with a physical disability will not be excluded from the Program unless deemed appropriate by the Clinical Coordinator after subsequent discussion with the client and her GP.

If greater detail is required, please refer to the Clinical Services Manual located in:

Q:\CH\CY&W\BScreen\Policies and Procedures

2 Clients with an Intellectual Disability

The radiographers are to perform the screening mammogram only in cases where consent has been obtained by the client’s Legal Guardian prior to the client’s presentation to the clinic. It is at the discretion of the client and the radiographer as to ascertain that at any time, the screening mammogram may be impossible or in fact, considered inappropriate to be continued due to the expressed discomfort of the client regarding the positioning required by the radiographer to perform and/or the radiographer is placing herself at risk regarding acquiring a physical injury herself while trying to position the client.

The radiographer will be mindful regarding the emotional needs of the client and the positioning needed and ensure continued consent (if deemed appropriate to do so) is sought throughout the screening episode. The radiographer must also be mindful of one’s risk of personal injury while attempting the mammogram.

If deemed appropriate, the radiographer is to:

discuss future management options with the attending Carer which should include uncertainty over the Program’s future suitability for the client regarding management of her breast health

create a BIS ‘Attention Medical Officer’ note stating all the details regarding the attended appointment and conversation had between client, Carer and radiographer regarding the experience of the mammogram

Clients with an intellectual disability will not be excluded from the Program unless deemed appropriate by the Clinical Coordinator after subsequent discussion with the Legal Guardian and the client’s GP.

If greater detail is required, please refer to the Clinical Services Manual located in:

Q:\CH\CY&W\BScreen\Policies and Procedures

9 Screening and the Lactating Client

1 Overview/Procedure Description

Clients who are breast-feeding at the time of their screening are advised at the time of making their appointment the following information. Failure to comply with the instructions will lead to the radiographer declining to perform the mammogram. The Declined process (9.10 Declined Clients) is to be followed.

If greater detail is required, please refer to the Clinical Services Manual located in:

Q:\CH\CY&W\BScreen\Policies and Procedures

2 Areas of Responsibility

Client support administration staff at the time of making the appointment. All radiography staff at the screening appointment.

3 Procedure Detail

1 Baby/toddler is accompanying the client

The client must breastfeed prior to having her mammogram. The client must have in attendance a carer for the baby/toddler while having her mammogram.

2 Baby/toddler not accompanying the client

The client is to breastfeed as close in time as possible prior to having her mammogram. It is recommended the client breastfeed and then to make her way directly to the clinic where her appointment has been made.

10 Declined Clients

1 Overview/Procedure Description

In certain scenarios, a client presenting for her screening mammogram is declined. Scenarios include but are not limited to:

the client is not due for her mammogram re date of her previous mammogram.

the client withdraws consent.

the client presents symptomatic.

2 Areas of Responsibility

Pre-screening appointment, staff responsible are:

Client support administration staff at the time of making the appointment.

All radiography staff at the screening appointment.

Post screening appointment, staff responsible are:

Administration at Reception.

Clinical Support Administration.

Nurse Counsellors.

On occasion, Clinical Coordinator.

3 Procedure Detail

1 When a client has had ZERO images performed

For instruction regarding the process of declining a client who has had no images performed at the time of her presentation, please refer to BIS Hints and Tips Radiography Booklet document located in:

Q:\CH\CY&W\BScreen\BIS\Hints and Tips - All staff\Snr Rad & Radiographers

If further detail is required, please also refer to the Clinical Services Manual located in:

Q:\CH\CY&W\BScreen\Policies and Procedures

11 Incomplete Clients

1 Overview/Procedure Description

In certain scenarios, a client’s screening episode results in having an Incomplete Status. This is apparent when the screening has started but is not able to be continued on the day. Scenarios include but are not limited to:

the client becomes ill during her mammogram

the client withdraws consent

there is an equipment failure

there is an unplanned Fire and Emergency evacuation

2 Areas of Responsibility

All radiography staff at the screening appointment.

Post screening appointment, staff responsible are:

Administration at Reception

Clinical Support Administration

On occasion, Clinical Coordinator

3 Procedure Detail

1 When a client has had one or more images performed but incomplete

For instruction regarding the process of an incomplete client who has had one or more images performed at the time of her appointment, please refer to BIS Hints and Tips Radiography Booklet document located:

Q:\CH\CY&W\BScreen\BIS\Hints and Tips - All staff\Snr Rad & Radiographers

If further detail is required, please also refer to the Clinical Services Manual located in:

Q:\CH\CY&W\BScreen\Policies and Procedures

12 Clients with Implanted Medical Devices (IMD)

1 Overview/Procedure Description

Clients who declare at the time of making their appointment that they have an IMD need consideration regarding the nature of their IMD. IMDs include but are not limited to:

Portacaths

Pacemakers

Defibrillators

If further detail is required, please also refer to the Clinical Services Manual located in:

Q:\CH\CY&W\BScreen\Policies and Procedures

2 Areas of Responsibility

Client support administration staff at the time of making the appointment. All radiography staff at the screening appointment.

3 Procedure Detail

1 Portacaths

If a client presents with a portacath in situ, she must have an accompanying letter from her treating Physician stating permission to perform the screening mammogram. Without written consent from the client’s Specialist, the client will be declined. The Declined process (9.10 Declined Clients) is to be followed.

2 Pacemakers – Defibrillators and other IMDs

If a client presents with any other IMDs in situ (i.e. other than a portacath), the radiographer is to explain clearly the potential limitations regarding compression, the possibility of breast tissue obstruction by the device and the care in positioning the radiographer will afford the client regarding the position, nature and location of her IMD in situ. If the client withdraws consent after these explanations and prior to having any images performed, the radiographer is to follow the Declined Client process (9.10 Declined Clients). If the client withdraws consent after these explanations and has had images taken, the radiographer is to follow the Incomplete Client process (8.12 Incomplete Clients).

13 Technical Repeat Workflow

For instruction regarding the process of technical repeats, please refer to BIS Hints and Tips Radiography Booklet document located in:

Q:\CH\CY&W\BScreen\BIS\Hints and Tips - All staff\Snr Rad & Radiographers

If further detail is required, please also refer to the Clinical Services Manual located in:

Q:\CH\CY&W\BScreen\Policies and Procedures

14 Clients Presenting with Private Prior Images

For instruction regarding the process whereby clients present with private prior images, please refer to BIS Hints and Tips Radiography Booklet document located in:

Q:\CH\CY&W\BScreen\BIS\Hints and Tips - All staff\Snr Rad & Radiographers

If further detail is required, please also refer to the Clinical Services Manual located in:

Q:\CH\CY&W\BScreen\Policies and Procedures

15 Clients who have Attended Another BreastScreening Service

For instruction regarding the process whereby clients declare they have attended another BreastScreening service in Australia, please refer to BIS Hints and Tips Radiography Booklet document located in:

Q:\CH\CY&W\BScreen\BIS\Hints and Tips - All staff\Snr Rad & Radiographers

If further detail is required, please also refer to the Clinical Services Manual located in:

Q:\CH\CY&W\BScreen\Policies and Procedures

16 Assessment Clinic Image Protocols

1 Overview/Procedure Description

Clients presenting for assessment are generally highly anxious and need sensitive management. Before starting any mammogram, x-ray or procedure, the radiographer verifies client identification details with the client regarding their full name and date of birth. The signed consent form, which is completed during the Nurse Counsellor’s consultation, is also checked at this stage prior to the start of the mammogram work-up procedure. If a suspected lesion or area is identified on the screening mammogram, further radiographic work up is required to more clearly define the nature of the lesion. All work-up images are performed by the assessing Radiographer and the nature of the work-up images are requested by the assessing Radiologist.

If further detail is required, please also refer to the Radiology Services section within the Clinical Services Manual located in: Q:\CH\CY&W\BScreen\Policies and Procedures

2 Areas of Responsibility

All assessing Radiology and Radiography staff.

3 Procedure Detail

Assessment of an abnormality may require one or more of the following work-up views.

Tomosynthesis

Repeat original view/s (MLO and/or CC including LAT)

Extended CC

Cleopatra

Buttocks view

Skin marker view

Spot compression

Magnification

Non-compression view

Ultrasound

1 Tomosynthesis Imaging

Tomosynthesis (i.e. 3-dimensional radiography) work-up images are performed by the assessing Radiographer. Position the client as for standard mammography views and use the tomosynthesis functionality on the Hologic equipment. The client is to be explained regarding the use of this new technology and subsequent longer time in exposure and need for no movement while the tomosynthesis scan is occurring.

2 CC, MLO and/or LAT Views

Please refer to 9.1 Basic Mammography Technique in this document.

3 Extended CC View

The client stands with the affected side to the detection plate. The client’s hand is positioned on the back of the detection plate and the height set slightly lower than the normal CC. The client is positioned slightly back and in towards the unit. Compression is adjacent to and not over the humeral head. The detection plate is angled 5-10 degrees towards the axilla if needed.

4 Cleopatra View

An exaggerated form of the extended CC. Pectoral muscle is usually demonstrated.

5 Buttocks View

For the medial area both breasts are lifted on the detection plate and the client is positioned as far forward as possible.

6 Skin-Marker View

Palpable lumps may pose special problems. If doubt exists whether a palpable lump and the demonstrated recalled mammographic lesion correlate, a lead skin marker or fuse wire may be used to place on the skin over the clinical lump site. This also applies to skin lesions. A tangential view may also be used to confirm the recalled lesion/calcification is not in the skin itself.

7 Spot Compression View

Localised compression is applied using a small spot compression paddle.

8 Magnification

May be used in conjunction with all previously mentioned views except the non-compression view.

9 Non Compression View

The posterior border of a posterior lesion may be demonstrated this way. Part of the superior breast tissue is lost from the image as compression is applied. By not compressing, detail of the image is lost but the posterior outline may be demonstrated.

10 Ultrasound

Further assessment may include ultrasound imaging of the breast/breasts. Ultrasound is only performed by assessing Radiographers who are academically qualified in Breast Sonography and/or Radiologists.

17 Vacuum Assisted Biopsy (VAB) – Tomosynthesis Guided

1 Overview/Procedure Description

This procedure is performed during an assessment clinic as an upright biopsy procedure on the Hologic equipment using tomosynthesis guidance. A detailed explanation of the procedure is given to clients at the assessment clinic by the assessing Radiologist performing the procedure (or in some instances, the assessing Clinical Coordinator). A consent form outlining the procedure and its potential risks is signed prior to the commencement of the procedure. Prior to the procedure, relevant information relating to the client’s previous medical history and current medication is obtained.

2 Areas of Responsibility

All assessing Radiology, assessing VAB Radiography staff and assessing Nursing staff.

3 Procedure Detail

The client should have ice applied to the relevant breast for 10 minutes before the procedure to minimize bleeding during the biopsy.

Immediately before the procedure the VAB radiographer verifies the client’s identity, side and site with the client and reiterates the information the assessing Radiologist has given to the client regarding the process required for the procedure. This explanation includes how long it should take, what position the client is placed in for the procedure, some information about the sampling technique and what after care might be necessary.

Support and reassurance to the client by the assessing VAB radiographer throughout the procedure is vital.

The direction of sampling e.g. cranio-caudal or lateral and position of the breast is discussed with the assessing Radiologist prior to the procedure commencing.

For full detail of the VAB procedure, please also refer to the Radiology Services section within the Clinical Services Manual located in: Q:\CH\CY&W\BScreen\Policies and Procedures

18 Core Biopsy - Ultrasound Guided

1 Overview/Procedure Description

This procedure is performed during an assessment clinic using the Philips Ultrasound equipment under ultrasound guidance. A detailed explanation of the procedure is given to clients at the assessment clinic by the assessing Radiologist performing the procedure (or in some instances, the assessing Clinical Coordinator). A consent form outlining the procedure and its potential risks is signed prior to the commencement of the procedure. Prior to the procedure, relevant information relating to the client’s previous medical history and current medication is obtained.

2 Areas of Responsibility

All assessing Radiology, assessing Sonography and assessing Nursing staff.

3 Procedure Detail

Immediately before the procedure the assessing Sonographer verifies the client’s identity, side and site with the client and reiterates the information the assessing Radiologist has given to the client regarding the process required for the procedure. This explanation includes how long it should take, what position the client is placed in for the procedure, some information about the sampling technique and what after care might be necessary.

Support and reassurance to the client by the assessing Sonographer throughout the procedure is vital.

For full detail of an Ultrasound guided Core Biopsy, please also refer to the Radiology Services section within the Clinical Services Manual located in: Q:\CH\CY&W\BScreen\Policies and Procedures

19 Fine Needle Biopsy – Ultrasound Guided

1 Overview/Procedure Description

This procedure is performed during an assessment clinic using the Philips Ultrasound equipment under ultrasound guidance. A detailed explanation of the procedure is given to clients at the assessment clinic by the assessing Radiologist performing the procedure (or in some instances, the assessing Clinical Coordinator). A consent form outlining the procedure and its potential risks is signed prior to the commencement of the procedure. Prior to the procedure, relevant information relating to the client’s previous medical history and current medication is obtained.

2 Areas of Responsibility

All assessing Radiology, assessing Sonography and assessing Nursing staff.

3 Procedure Detail

Immediately before the procedure the assessing Sonographer verifies the client’s identity, side and site with the client and reiterates the information the assessing Radiologist has given to the client regarding the process required for the procedure. This explanation includes how long it should take, what position the client is placed in for the procedure, some information about the sampling technique and what after care might be necessary. Support and reassurance to the client by the assessing Sonographer throughout the procedure is vital.

For full detail of an Ultrasound guided Core Biopsy, please also refer to the Radiology Services section within the Clinical Services Manual located in: Q:\CH\CY&W\BScreen\Policies and Procedures

Radiography Technical Quality Program

1 Quality Assurance (QA) and Quality Control (QC)

All radiographers are responsible for the daily, weekly and monthly QA and QC processes for all equipment. The Designated QA Radiographer performs the quarterly QA by being provided time away from her clinical load. The Senior Radiographer and Designated QA Radiographer need to be notified if any QA testing fails. If any equipment fails any QA testing, the equipment is not to be used for purpose until further testing is passed. This may include but is not limited to the QA test being repeated, Manufacturer service and/or Physicist testing.

BSACT’s QA and QC testing regime meets the following QA/QC Governing bodies:

BreastScreen Australia

RANZCR (Royal Australian and New Zealand College of Radiologists)

Manufacturer’s Recommendations

For full details of the QA and QC processes performed, please refer to the Digital Image Management Manual located in: Q:\CH\CY&W\BScreen\Policies and Procedures

2 Image Reject Analysis (Technical Repeat)

Images may be rejected according to the specific criteria listed in 11.1 Appendix 1 – NAS Accreditation Standards, PGMI Evaluation of Clinical Image.

The daily record and reasons for performing a technical repeat image at the time of the initial screening is entered into the BIS mammography screen by the screening radiographer. For instruction regarding the process of technical repeats, please refer to BIS Hints and Tips Radiography Booklet document located in:

Q:\CH\CY&W\BScreen\BIS\Hints and Tips - All staff\Snr Rad & Radiographers

A confidential reject analysis report is generated by the Senior Radiographer on a quarterly basis and supplied to all screening radiographers for analysis and personal reflection. If the results are deemed concerning from a performance perspective, the Senior Radiographer is to discuss with the radiographer and may include extra training and support strategies in a formal plan to improve performance.

This data is collected and distributed confidentially and individually by the Senior Radiographer to the staff as part of an ongoing quality review process and aims to continually improve screening techniques and realistically reduce the number of repeat films needed for clients in the program. The National Accreditation Standard 2.5.2 currently specifies no more than 2% of images should be rejected on technical grounds.

3 Technical Criteria – PGMI Methodology

1 PGMI (Perfect, Good, Moderate, Inadequate) Image Evaluation

In accordance with BreastScreen Australia’s Protocols 2.4 PGMI Image Positioning Quality Assurance (QA), BreastScreen ACT has adopted a grading system for image quality evaluation in accordance with BreastScreen Australia’s PGMI evaluation of clinical image quality. Images are assessed in accordance to the specific criteria listed in 11.1 Appendix 1 – NAS Accreditation Standards, PGMI Evaluation of Clinical Image.

Radiographers, during the Clinical Module week and/or during orientation are familiarised with the PGMI evaluation system.

At the time of screening, a radiographer is to enter their personal PGMI rating of their images. For instruction regarding the process of entering one’s PGMI rating, please refer to BIS Hints and Tips Radiography Booklet document located in:

Q:\CH\CY&W\BScreen\BIS\Hints and Tips - All staff\Snr Rad & Radiographers

BreastScreen ACT conducts PGMI analysis biannually and is performed by the Designated PGMI Radiographer. The PGMI analysis is confidentially given to the radiographer for analysis and personal reflection. If the results are deemed concerning from a performance perspective, the PGMI Designated Radiographer is to discuss with the Senior Radiographer in the first instance and then with the radiographer and this discussion may include extra training and support strategies in a formal plan to improve performance. Radiographers should use the PGMI criteria, not only as a guide to their standard of image quality but also as a tool in troubleshooting.

In conjunction with the manual process of PGMI analysis performed by the PGMI Designated Radiographer, cross referencing (of the identical client cohort) with self-graded PGMI ratings is also performed by using the operational generated BIS Self-Audit PGMI report. This allows greater self-reflection as to ascertain whether the screening radiographer understand thoroughly the PGMI rating standards.

Please see 11.1 Appendix 1 – NAS Accreditation Standards, PGMI Evaluation of Clinical Image for the details regarding full evaluation criteria.

Acceptance of minor artifacts while acquiring an image that do not obscure the breast tissue and/or do not decrease the integrity of the image to an extent where it is deemed worth repeating is not repeated in order to attain a higher PGMI rating. Folds that do not obscure breast tissue and/or equipment artifacts are examples of such minor artifacts.

N.B. The current PGMI Standards have been under review since the introduction of digital imaging across Australia. The most current draft version available ‘PGMI Digital Image Reference Set – Draft Version 2 – 2012’ can be found at or on BSACT’s local network Q:\CH\CY&W\BScreen\Chief Radiographer\PGMI.

2 Image Quality Assurance

The National Accreditation Requirements specify that each radiographer annually demonstrate an achievement of 50% or greater P or G ratings in a PGMI evaluation of 50 randomly selected film sets. The Designated PGMI Radiographer will be given time away from her clinical load to assess each radiographer's set of random 50 clients and will present the Senior Radiographer with a confidential report on the Practice as a whole including individual results of staff.

3 PGMI Theory – Practice Standard Methodology

The Designated PGMI Radiographer will set a 'Practice Standard' regarding knowledge of PGMI standards as a performance measurement tool for the Senior Radiographer to use to monitor staff knowledge of NAS digital PGMI standards. Each new and existing radiographer will need to meet the Practice Standard for PGMI image quality theory. Once a practice standard is attained, any new radiographers will sit the PGMI Practice Standard test monthly, until they attain the expected Practice Standard. Existing radiographers will sit the test quarterly. If the Practice Standard is not met, existing radiographers will re-sit the test monthly until acquiring the Practice Standard. The Designated PGMI Radiographer will provide ongoing one to one tutoring and training and reference material to the radiographers who fail the Practice Standard to assist in increasing their PGMI theoretical knowledge.

4 PACS Viewing of Images at Time of Reading

In conjunction with the radiographer self-assessment process at the time of screening, any Reading Radiologist has the opportunity to raise concerns regarding image quality presented to him/her at the time of reading by selecting Technical Recall as reading outcome in BIS. The Senior Radiographer routinely checks for Technical Recalls in the BIS Follow Up Appointments screen during the week but particularly at the time of the Triage process. For instruction regarding the Technical Repeat process for both the Senior Radiographer and the screening radiographer, please refer to BIS Hints and Tips Radiography Booklet document located in:

Q:\CH\CY&W\BScreen\BIS\Hints and Tips - All staff\Snr Rad & Radiographers

4 Personal Radiation Monitoring (PRM)

All Radiographers (and the current PACS Administrator) working in the clinical environment wear a radiation monitor. The types of monitors used are the PB15T – personal radiation monitors. These are monitored and results analysed by Australian Radiation Services on a quarterly basis. Radiation monitoring is centralised across all of ACT Health. If a radiographer is pregnant, her monitor must be monitored monthly.

For further detail regarding PRMs, please see Appendix 2 – Procedure Outline for Management of Personal Radiation Monitors (PRM).

5 Continuing Professional Development (CPD)

1 Overview/Procedure Description

Radiographers employed at BSACT are required to participate in a CPD program approved and implemented by either the Medical Radiation Practice Board of Australia (MRPBA) under Australian Health Practitioner Regulation Agency (AHPRA) or with the Australian Society of Medical Imaging and Radiation Therapy (ASMIRT). The Senior Radiographer is expected to monitor the CPD of each staff member.

2 Areas of Responsibility

All Radiographers including the Senior Radiographer.

3 Procedure Detail

All radiographers are expected to enrol and maintain their individual MRPBA or ASMIRT CPD Program. It is the responsibility of the radiographer, to provide the Senior Radiographer of the details of their chosen CPD Program including the details of which cycle and expiry date of their respective triennium.

1 MRPBA CPD Program

Enrolment and participation in the MRPBA CPD Program is open to all AHPRA members. For a comprehensive guide to the MRPBA CPD Program, please refer to ‘Medical Radiation Practice Board Guidelines CPD’ located at:

Q:\CH\CY&W\BScreen\Chief Radiographer\CPD Programs OR

Visit the MRPBA website at .au

2 ASMIRT CPD Program

Enrolment and participation in the ASMIRT CPD program is provided to all members and non-members. For a comprehensive guide to the ASMIRT CPD Program, please refer to ‘Guide to AIR Continuing Professional Development Triennial Program’ located at:

Q:\CH\CY&W\BScreen\Chief Radiographer\CPD Programs OR

Visit the ASMIRT website at

6 Certificate of Clinical Proficiency in Mammography (CCPM)

All BreastScreen radiographers are required to work towards achieving their CCPM. This may include attending training courses at either state or national level or participating in regular ongoing education.

Radiographers are encouraged to attend workshops, audit meetings, quality assurance workshops and relevant conferences.

Screening staff will be rostered to work in assessment clinics throughout the year. A minimum of two assessment clinics per radiographer per year will meet BreastScreen Australia’s recommendation.

7 Designated Radiologist feedback

Regular communication between the Designated Radiologist and Senior Radiographer will occur to discuss such issues (but not limited to) relating to quality assurance, processes, new policies and image standards. The monthly audit meeting is conducted in a multidisciplinary setting and is where discussion regarding assessment client follow up and/or interesting cases will be discussed with an educational focus.

For full detail regarding the Multidisciplinary Clinical Audit Meetings, please refer to the Radiology Services section within the Clinical Services Manual located in: Q:\CH\CY&W\BScreen\Policies and Procedures

Equipment

Equipment service logbooks and records of repairs and/or adjustments are maintained at screening and assessment centres. For further information regarding the Quality Assurance and Quality Control measures taken by BSACT, please refer to Section 9.11 Quality Assurance and Quality Control of this document and for comprehensive detail, please refer to the Digital Image Management Manual located in: Q:\CH\CY&W\BScreen\Policies and Procedures

1 Equipment or Software Failure

If any equipment and/or software used to support the screening process including, but not limited to the, Picture Archival System (PACS), the BreastScreening Information System (BIS) and the ACT Patient Administration System (ACTPAS), fails during a screening session, radiography staff need to:

Contact the appropriate stakeholder and establish likely down time

Decide whether clients need to be cancelled and/or rescheduled

Contact the Senior Radiographer with timelines and issues

1 Maintenance and Fault Logging

When managing an equipment breakdown and/or software failure, it is important for the radiographer involved to record the following:

Date maintenance or fault noted

Description of fault encountered and / or maintenance performed

Name of person making entry

Action taken by the radiographer in first instance

Faults are added to the error log icon on the modality screen

Resulting report (if site visit applicable by Engineer and/or Medical Physicist) is received

appendices

1 Appendix 1 – NAS Accreditation Standards, PGMI Evaluation of Clinical Image

2 Appendix 2 – Outline for Management of Personal Radiation Monitors (PRM)

BreastScreen ACT assigns one of the mammographers as the Dedicated Radiation Officer (DRO) who works closely with the Senior Radiographer and the Medical Physics and Radiation Engineering department at The Canberra Hospital to ensure compliancy and comprehensive management of PRMs.

PRMs are delivered directly to the service from the Australian Radiation Protection and Nuclear Safety Agency (ARPANSA). All correspondence with ARPANSA is via their email: prms@.au

The DRO receives a quarterly written report from ARPANSA and discusses the findings with the Senior Radiographer. If there are any anomalies regarding dosage readings of staff, the Senior Radiographer discusses this with the relevant staff member regarding advice and future follow up.

3 Appendix 3 – BIS Hints and Tips for Radiographers 2017 V2

See separate document.

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BreastScreen ACT

Radiography

Manual

[pic]

Version 4

2017

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