3DARKROOM CLEANLINESS NEVER: ALWAYS: Carpet a darkroom Store boxes or cartons and never openALWAYS:Have shelving with doorsReplace filters and service air conditioningWipe countertops with damp clothWipe film trays with anti-static solutionUse a black light
4SENSITOMETRY Must use same box of film Must be performed before clinical filmsCheck Developer temperatureFlash sensitometric strip on emulsion sideSpeed and Contrast Index within +/-.15B+F within +/-.03Developer within +/-.5 degreesAn increase in developer temp will affect other values: increase in B+F and decrease in density difference.If developer normal, those changes may indicate a need to change chemicals.
5SENSITOMETRY When data falls outside of the limits Trends Documentation
6SCREEN CLEANLINESS Clean when 3-4 specks shown Use Antistatic solution 4x4 rayon or lintless 100% cotton padsWipe in circular motion from center outLet dryUse one of many tools available to get rid of dustCheck with black lightDiscard old film (costly)Load with new film
7VIEWBOXES Clean weekly to remove dust, smudges, etc Change bulbs every 12-18monthsTest luminance with light meter (not required by MQSA)When changing bulbs, clean inside of viewboxes and change all bulbs
8PHANTOM IMAGING Monitors whole system Simulates a 4.5 cm compressed breastConsists of 6 nylon fibers, 5 oxide specks, 5 tumor massesShould be performed:After any serviceAfter changes in chemistry or filmWhenever changes in image quality suspected
9PHANTOM PROCEDURE AEC placed same as a 4.5 cm breast 4mm acrylic disc placed away from objectsBackground density: center, 1.2 OD +/-.2Density difference: .4 +/-.05 for films at 28kVpChart mAs to evaluate reproducibility (should not vary more than +/-.15)
10PHANTOM ANALYSIS Must see 4 fibers, 3 specks, 3 masses (10) Can vary +/-1 but no lower than 10 objects.Viewed:By same personSame time of dayOn same viewboxUnder same viewing conditionsUsing same type of magnifying lens
13VISUAL CHECKLISTTakes inventory of room to ensure safety, comfort and convenience
14FIXER RETENTIONPerformed right after daily strip on emulsion side in clear areaPlace drop of fixer and let sit 2 minutes (do not expose to bright light)Blot dry and place on white cardboardCompare to chart. No more than 5ug/cm squared (3 on the chart)
15REASONS FOR ELEVATED FIXER Inadequate wash water flow ratePartially depleted fixer (enough activity for clearing but not enough for hardening)Insufficiently hardened emulsion retains too much fixer for wash to remove.RESULT: Degrades stability of image
16FIXER CORRECTIONIncrease fixer replenishmentIncrease water flow
17REPEAT/REJECT ANALYSIS To evaluate reasons films are repeatedPoints out insufficiencies, wasteCan improve efficiency
18REPEAT ANALYSIS PROCEDURE Quarterly and at least 250 patients examinedFilms are categorizedACR states number of repeats should be no greater than 5%.
20COMPRESSION Image quality and safety test Test in both power drive and manualMQSA states 25 – 47 lb range
21How does compression improve quality? Decrease scatterDecrease doseDecrease patient motionIncrease contrastIncrease uniformity of breast tissueIncrease image sharpness by decreasing thickness thus decrease focal spot degradation
22COMPRESSION PROCEDURE Place towelPlace scalePlace friend’s (soon to be enemy’s) breast on top of scaleCompress in power mode until it stops (never mind the screaming of your new enemy)Compress in manual until it stops (same as above)
23COMPRESSION PROCEDURE Place towelPlace scalePlace several towels on top of scaleCompress in power until it stopsCompress in manual until it stops
24FILM/SCREEN CONTACT Performed on all new cassettes and/or semi-annual More critical than general radiographyHighlights areas of decreased sharpnessFine copper wire mesh screen usedMore critical because of its high resolution which is attained through single emulsion with small crystals and screens with small phosphorsDamage to screens not noticeable with clinical films so this test highlights areas of decreased sharpness.
25FILM/SCREEN CONTACT PROCEDURE Clean cassettesLet sit for 15 minutesEmploy 25-28kVp, no grid, manual mas with .5 secondsPaddle all the way up with acrylicWire mesh on top of screen
26FILM/SCREEN ANALYSIS .7-.8OD near chest wall Stand 3-6ft back If densities over 1 cm appear, clean and retest.Remove if large density still appears.Several small densities acceptable.
27DARKROOM FOG Inspect with all lights off Be aware of luminescent or phosphorescent itemsUse radiation exposed filmMQSA states fog should be no >.05 OD when exposed for 2 min.Problems usually lie in safelight position or filters
28DARKROOM PROCEDURE Load cassette in total darkness Expose phantom to 1.0 ODInspect safelightsTurn off lights, inspectRemove film, insert into template emulsion upExpose sections to safelightsRun film then measure densities on each side of lines
30Safelights Filters should correspond with green light sensitive film Lamps ~4 ft from work areaWratten 1 or 2, Kodak GBX-2 good examples of filtersNo >15watt bulb in overhead fixtureNo >7.5 watt in closer fixturesPrinting on filter should face outChange filters every 1-2 yearsHeat from higher watt bulbs could ruin filtersFilm should be stored away from radiation, heat, chemical fumes.
31AIR QUALITY Temperature: 70 degrees F Humidity: 30-50% Ventilation: for image quality and technologists’ healthWhen film is exposed to excessive heat, its emulsion softens and is more susceptible to scratching.A cooler temp causes emulsion to crack and peel.If air dry <30%, static marks appear.If humidity above 50%, water droplets from air may cling to film and cause emulsion to clump. Image will appear as if misted with ink.Ventilation of processor: if no air going in or coming out (remove hose and put hand over hole) then streaking and mottling of emulsion can occur.Can give techs headaches and nausea due to chemical fume buildup.
33PROCESSOR MAINTENANCE Developer temperatureIncrease can cause fogDecrease can result in:Decrease in film speed and contrastHigher dose to ptFixer temperatureDecrease can affect archival of filmWash-water temperatureCan cause biological growth in tankCan affect developer and fixer temps, improper wash
34PROCESSING CONTINUED… Chemical replenishmentRates inconsistent when processor left on and not usedCheck solution levelsIf solution levels too low, sediment could get in to the processor and cause damage. Would need to empty tanks and clean.
35PROCESSING: STANDARD Typically used for general radiography Faster cycle time (usually 90sec)Developer immersion ~23 secCan accommodate single and double
36PROCESSING: EXTENDEDDifference from standard is developer immersion time (~45sec)“Push” more contrast and speed from the filmLess exposure needed with increase in film speedIncrease in tube lifeDownfall is an increase in noise
37TYPES OF PROCESSORS Small desktop DISADVANTAGES ADVANTAGES Straight-through require careful adjustments to replenishmentDeveloper not sprayed evenlyADVANTAGESCost, small, fewer rollers, two developer stations,Less chance of oxidation
38TYPES OF PROCESSORS Large stand-alone DISADVANTAGES ADVANTAGES Artifacts from rollersSpaceADVANTAGESAgitates chemicals which increases supply of fresh chemicals
39ARTIFACTS Processing Environmental Handling Positioning Equipment White artifacts indicate pressure on emulsion before exposure
40SENSITOMETRIC STRIP Establishing the baseline Expose and process 5 stripsAverage readings for temporary baseProcess one strip per day for 5 daysIf strip is out of tolerance, correct and repeatWatch for trend due to seasoning effectAverage these 5 strips for new baseBaseline maintained unless film, chemistry or processing altered
41CROSSOVER Performed when changing box of film 10-12 sheets remaining in old boxDo not perform after processor cleaning
42CROSSOVER PROCEDURE Perform in total darkness Expose 5 old and 5 new Alternate old and newDistinguish old from newMeasure steps used in daily QCAverage 5 readings from each boxSubtract old from newAdd/Subtract results to/from original aim values
43CROSSOVER RESULTS Results must be within +/- .10 If greater than .15 difference, contact film manufacturer representative
44(Dudes Prefer) (Sex, Violence and Partying) over (Visiting) (Relatives For) (Christmas Day Feasts.)
46QUALITY ASSURANCEDefined as all those planned and systematic actions necessary to provide high image quality.
47QUALITY MANAGEMENTPart of the management function which determines and controls quality policy.Making appointmentsCall back protocolObtaining previous mammogramsPatient educationPatient intakeProblem solving
48QUALITY CONTROLThe set of operations necessary to maintain or improve quality.
49QUALITY SYSTEM Assignment of responsibility Establishment of standards Staff trainingProper documentation of proceduresQC of equipment at installation and throughout its life
50MQSA of 1992As of Oct 1, 1994, all mammography facilities in the U.S. (except those of Dept of Veterans Affairs) were required to be certified by the FDA as meeting mammography quality in order to lawfully continue to perform Mammography.Goal: to assure that Mammography is safe and reliable to allow detection of breast CA in its earliest most treatable stages.
51MQSA REGULATIONSTo operate lawfully, a mammography facility must be certified by the FDA.In order to be certified, a facility must first be accredited by a federally-approved private nonprofit or state accreditation body.To be accredited, the facility must undergo periodic review of clinical images; surveyed annually by a medical physicist; meet standards for personnel qualifications, equipment QA programs, and record keeping and reporting.Facility must undergo annual inspections.
52ACCREDITATION A survey form completed by facility Phantom images submitted to evaluate image qualityDosimeter visible on phantom and dose measuredClinical images submitted for evaluationOnce initial paperwork approved, facility submits 30 days of processor QC stripsCLINICAL IMAGESOne set of fatty breasts and 1 set of dense breast images evaluated. Must demonstrate adequate positioning, compression, exposure level, contrast, exam identification, etc.
53CERTIFICATIONAwarded by the FDA as providing quality mammography services.This is awarded upon accreditation by a federally-approved accreditation body: ACR; States of Arkansas, California, and Iowa
56Interpreting Physicians Initial Qualifications State licenseDiagnostic radiology certification OR 3 months of formal training60 hours of category I CME in mammography240+ mammograms interpreted under direct supervisionIn the 6 months immediately prior to independent interpretation ORIf board certified at first allowable time, within the last 2 years of residency
57Interpreting Physicians Continuing Requirements Continuing experienceInterpret at least 960 examinations / 24 monthsContinuing educationAt least 15 category I CME credits / 36 monthsAt least 6 of the 15 CME units must be in each mammographic modality used8 hours of training in each mammographic modality before independent use
58Radiologic Technologists Initial Qualifications State license OR certified by FDA-approved body40 hours of documented mammography trainingPerforming at least 25 examinations under direct supervision8 hours of training in each mammographic modality to be used
59Radiologic Technologists Continuing Requirements Continuing experienceAt least 200 examinations / 24 monthsContinuing educationAt least 15 CEUs / 36 monthsAt least 6 of the 15 CEUs must be in each mammographic modality used8 hours of training in each mammographic modality used before independent use
60Radiologic Technologists Reestablishing Qualifications Continuing experienceComplete 25 examinations under direct supervisionContinuing educationBring total continuing education credits up to 15 CEUs / 36 months
61Medical Physicists Initial Requirements Licensed or approved by a State OR Certified by FDA-approved bodyMaster’s or higher degree in a physical science20 semester hours of physics20 hours of documented mammography survey trainingOne facility and 10 units surveyed8 hours of training in each modality surveyed before surveying independently
62Medical Physicists Alternative Initial Requirements* Licensed or approved by a State OR Certified by FDA-approved bodyMaintained active statusFor physicists who were qualified under the interim regulations
63Medical Physicists Alternative Initial Requirements* (cont.) Prior April 28, 1999, have:Bachelor’s degree in physical science with at least 10 semester hours of physics40 hours of documented mammography survey training after earning the bachelor’s degreeOne facility and 20 units surveyed after earning the bachelor’s degree
64Medical Physicists Continuing Requirements Continuing experienceSurvey at least 2 facilities and 6 units / 24 monthsContinuing educationAt least 15 CEUs / 36 months8 hours of training in any modality before surveying independently