Audit of Adult Chest Radiographs (PA Views) Done in JPD ...



Audit of Adult Chest Radiographs

(PA Views) Done in JPD HTAA, Kuantan

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Dr.Allah Rakha Dar

Pegawai Perubatan

Jabatan PengimejanDiagnostik

Hospital Tengku Ampuan Afzan

Kuantan, Pahang Darul Makmur

Audit of Adult chest Radiographs (PA views) done in J.P.D HTAA, Kuantan

Introduction

Chest radiographs ( PA- CXR) are the most common X-ray investigation asked for in this department. They include requests from out- patient, In- patient, A&E and routine medical examinations. Audit of last four-year work load showed that CXR accounts for 30% of total workload (Fig. 1). Routine medical examination accounted for 40% of the PA-CXR. As 95% of individuals under going routine CXR for medical examination are healthy, hence it is a waste of resources to repeat the CXR for avoidable technical reasons.

An ideal CXR should provide an image of all structures present in the chest at minimum radiation. There are ten accepted criteria for a good quality PA- CXR.

1. Correct exposure: - Vertebral bodies of thoracic 1-4 should be visualized.

2. Good inspiration: - six anterior or ten posterior ribs should be visualized.

3. Symmetrical positioning of thorax: - Sternoclavicular joint should be equi-distant.

4. Positioning of scapulae: - Medial border of scapulae should be out side of the lung field.

5. Visualization of lung fields: - Reproduction of vascular patterns in the whole lung particularly the peripheral vessels.

6. Visualization of the whole rib cage above he diaphragm.

7. Sharp visualization of chest anatomy: - visualization of trachea, proximal bronchi, heart borders and aorta/ diaphragm and costo-pherenic angles.

8. Visualization of retro cardiac lung and mediastinum.

9. Conning of film: - just below the diaphragm, side cone should include the rib cage and part of shoulder joints.

10. Identification marks, date, X-ray number, patient’s name, left, right and PA markers should be clear.

This study was planned to assess the quality of CXR done at J.P.D. HTAA based on the above- mentioned criteria and compare with the standards elsewhere.

Methodology

This was a prospective study done in June 2000. One hundred CXR were randomly selected for the study, regardless of any bias for any radiographer. The X rays were scored on the scale of 10, where each criterion was given a score of one. All those X-rays which full filled all 10 criteria were given a perfect score of 10. The X- rays below the score of 8 were considered sub-standard (HKL Journal of Quality Improvement 1999, vol 3, No 1). Re-evaluation study was done in Sept. 2000 after remedial actions were implemented following identification of causes of sub-standard CXR.

Results

The initial study showed that the most common problem was rotated radiographs, which accounted for 24% of CXR. Other major areas of weaknesses are listed in

Table No.1.

Table No. 1

|Major problems |Percentage |

|Rotated films |24% |

|Over / under exposed films |15% |

|Scapulae inside the lung fields |12% |

|Conning not at the shoulders |10% |

|Score |No. Of X-rays |Percentage |

|10 |24 |24% |

|9 |20 |20% |

|8 |31 |31% |

|7 |15 |15% |

|6 |8 |8% |

|5 |2 |2% |

|Total |100 |100% |

Table no. 2 shows the distribution of X-rays according to the scoring.

Table 2: Frequency distribution of radiograph according to scores

(June 2000)

|Criteria |Frequency |

|Correct exposure |84% |

|Good Inspiration |96% |

|Symmetrical position of thorax |76% |

|Proper positioning of scapulae |88% |

|Good visualization of lung pattern |97% |

|Whole rib cage included |97% |

|Sharpness of chest anatomy |98% |

|Clarity of retro-cardiac area |98% |

|Proper conning |90% |

|Identification and markers |99% |

Table 3: - Frequency distribution according to ten standard criteria.

Remedial Action

Following the study suggestions were invited from the radiographers to over come these problems. The suggestions were-

a) Putting up of the identified problems on the quality assurance board as well as Chest radiography room.

b) Frequent discussions about identified problems among the radiographers.

c) Double check system specially for positioning of the patient.

d) It was identified that although optimal technique factors were applied, there was workload pressure on the radiographers. Suggestion regarding improvement were accepted & promised to be addressed maximally.

Results of Re-evaluation study

In Sept. 2000 re-evaluation study showed significant improvement of the quality of chest radiographs. In this study the general problems were studied with an emphasis on the major problems identified in the preliminary study.

Table 4: - Re-evaluation of major problems (Sept. 2000)

|Major problems |Percentage |

|Rotated radiograph |22% |

|Under/ over exposed radiograph |6% |

|Scapulae in the lung fields |15% |

|Conning not at the shoulders |3% |

|Score |No. Of radiographs |Percentage |

|10 |11 |11% |

|9 |55 |55% |

|8 |23 |23% |

|7 |8 |8% |

|6 |0 |0% |

|5 |3 |3% |

|Total |100 |100% |

Table 5: - Frequency distribution of radiographs according to score (Sept. 2000)

Table 6: - Comparison of PA – CXR in June 2000 & Sept. 2000

| June 2000 September 2000 |

|Standard 75% 89% |

|Sub- Standard 25% 11% |

Study showed significant reduction in under and over exposed radiographs and improvement in conning at the shoulder. There was no significant reduction in rotated radiographs and in fact there was an increase in the number of radiographs with scapulae in lung fields.

Machine performance history was taken from radicare records there were several complaints about the main chest radiographic machine pertaining to its non- alignment in centring. The concerned company was unable to correct the fault due to technical reasons and the radiographers have no alternative except to depend on the same machine until it is replaced or repaired.

The problem of inability of throwing the scapulae out of the lung fields was discussed; the main contributing factor was identified to be patient’s old age and serious illnesses.

Discussion

Standard chest radiographs remain the commonest request. Production of sub-standard x-rays lead to missed or delayed diagnosis, repeat examinations and increased radiation dose to the patients. Author is particularly concerned about repeat radiographs for routine medical examination which are 95% healthy individuals. Contributory factors could be faulty machine, poor knowledge of radiographers, wrong positioning of patients. Most radiographers did not include parts of shoulders or bones. Pathology found in lungs could be related to bony areas. Audit of CXR in GH K.L showed that 23% of radiographs were sub-standard quality and the main causes were almost similar to our study excect over/ under exposed radiographs, which were significant in our study. Remdial measures were implemented which included regular consultation with senior radiographers, fortnightly CME with radiographers and guidelines for exposure factors. These all measures helped to reduce sub-standard quality radiographs to 11%. Regular servicing of x-ray and processing machines is necessary to avoid faulty machines. Auditing of CXRs should be done at least every 6-9 months to monitor the radiographs quality.

Conclusion

First study revealed that 25% of the radiographs were of sub-standrad quality. The main causes were wrong positioning, lack of proper collimation, on-usage of optimal radiographic factors and scapulae in lung fields. Re-evaluation study showed that sub-standard radiographs dropped to 11%. Although it is higher as compared to studies elsewhere because of permanent machine problems but still acceptable. Regular quality auditing is the answer for continuous maintenance of standard. These types of studies are meaningful only if they are briefed to all radiographers and remedial measures are implemented.

Advisor

I would like to pay special thanks to Dr. Zainun A. Rahman, Head of Department of Radiology, HTAA, Kuantan whose continous support and advise mad this study possible.

Acknowledgement

I would also like to thank Ketua juru x-ray Puan Hajjah Zauyah, Haji Sabri and all the radiographers who participated in the study.

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