Chapter Two

Literature review and previous

studies
 Chapter two
Literature review and previous studies
2.1 Radiation Protection:
Since the end of the 19th Century, radiation has been used for many
beneficial purposes. Today, many sources of radiation, such as x-ray
machines, linear accelerators and radionuclides are used in clinical and
research applications. Such beneficial uses may at times create potentially
hazardous situations for personnel who work within the hospital. (9)
The ability of x-rays to cause injury in normal biologic tissue soon
became apparent as well. Hence, since the early 1900s both the beneficial
and destructive potentials of x-rays have been known. X-rays are a form
of ionizing radiation. When passing through matter, ionizing radiation
produces positively and negatively charged particles (ions). The
production of these ions is the event that may cause injury in normal
biologic tissue. (10)
At the turn of the Millennium, the year 2000, the National Academy of
Sciences identified the 20 greatest scientific and technical
accomplishments of the 20th century. Medical imaging was number 14
on this list. (11)
The current widely accepted approach to radiation protection throughout
the world is supported by an international system based on advice from
International Commission on Radiological Protection (ICRP, 1990;
2007). It relies on three principles – justification, optimization and dose
limitation, which provide the basis for the components of the radiation
protection framework mentioned above, that is professional development;
regulation/governance; and safety culture. Though primarily designed
with occupational and public exposures in mind, the system is being
reviewed and adapted – not always successfully – to address medical
exposures. This is particularly so since the mid to late 1990s (EC, 1997;
IAEA, 2001). (12)
All health physics activity in radiology is designed to minimize the
radiation exposure of patients and personnel. Three cardinal principles of
radiation protection developed for nuclear activities—time, distance, and
shielding—find equally useful application in diagnostic radiology. When
these cardinal principles are observed, radiation exposure can be
minimized. (12)
2.1.1 International Commission on Radiological
Protection (ICRP):
The International X-ray and Radium Protection Committee was
established in 1928 for the purpose of protecting healthcare workers from
radiation hazard. In 1950, the committee was reorganized into the
International Commission om Radiological Protection (ICRP), which was
assigned a significant role as an international organization that makes
recommendations concerning basic frameworks for radiological
protection and protection standards. In recent years, the Commission
made recommendation in 1977, 1990 and 2027.When the ICRP releases
its recommendations, many countries review their laws and regulations
on radiological protection accordingly. (13)
ICRP Recommendations are based on wide-ranging scientific knowledge,
such as that obtained through epidemiological studies on atomic bomb
survivors, and its radiological protection system has been maintained
since 1990 on the basis of its position that comprehensive estimation of
deterministic effects (tissue reactions) and stochastic risks is basically
unchanged. (13)
The commission aims to make recommendation concerning basic
framework for radiological protection and protection standards. The
commission consists of the Main Commission and four standing
committees (radiation effects, dose from radiation exposure, protection in
medicine, and application of the Commission's recommendations). (13)
2.1.1.1 ICRP'S Three Fundamental Principles of Radiological
Protection:
2.1.1.1.1 Justification in The Use of Radiation in Medicine:
The first principle is the justification of radiological protection. This is
the fundamental principles that an act of using radiation in permitted only
(13)
when the benefits or merits outweigh the radiation risks.
Medical exposures should be justified by weighing the diagnostic or
therapeutic benefits they produce against the radiation detriment they
might cause, taking into account the benefits and risks of available
alternative techniques that do not involve medical exposure. (8)
This principle is applied not only to acts of using radiation but also to all
activities that bring about changes in exposure situations. In other words,
this is also applied to emergency exposure situations and existing
exposure situations, as well as to planned exposure situation. For
example, justification is required even in the case of considering
decontamination areas. (13)
The balance of benefit and risk from medical exposures is considered at
three levels of justification (Fig 2-1). Generic justification at International
Commission on Radiological Protection (ICRP) level 2 has been the
focus of much work and interest globally, with a number of tools
available to improve the process of justification by referring and
radiological practitioners. This forms part of a larger move to improve the
system of benefit–risk assessment, which takes in three key steps:
awareness, appropriateness and audit (the ‘three As’). (14)
(Fig2-1): Justification of medical exposures at three levels as identified
by the International Commission on Radiological Protection.
2.1.1.1.2 Optimization for Medical Exposures in Radiology:
The second principle is the optimization of radiological protection. When
merits of an act of using radiation outweigh radiation risks, it is decided
to use radiation by taking measures to reduce exposure doses as low as
reasonably achievable (ALARA). This is called the ALARA principle.
The optimization of radiological protection means to strive to reduce
exposure doses as low as possible, while taking into consideration social
and economic balances, and does not necessarily mean to minimize
exposure doses. (13)
Optimization is defined in the IAEA Safety Glossary as the ''process of
determining what level of protection and safety would result in the
magnitude of individual doses, the number of individuals (workers and
members of the public) subject to exposure and the likelihood of
exposure being as low as reasonably achievable, economic and social
factors being taken into account''. (15)
In relation to exposures from any particular source within a practice,
except for therapeutic medical exposures, protection and safety shall be
optimized in order that the magnitude of individual doses, the number of
people exposed and the likelihood of incurring exposures all be kept as
low as reasonably achievable, economic and social factors being taken
into account, within the restriction that the doses to individuals delivered
by the source be subject to dose constraints. (14)
2.1.1.1.3 Application of Dose Limit:
The third principle of radiological protection in the application of dose
limits. The 2007 Recommendations of the ICRP specify the effective
dose limit for occupational exposure (excluding radiation work in an
emergency) as 100 mSv per five years and 50 mSv for the specific one
year. (13)
The effective dose limit for public exposure is specified as 1 mSv per
year. Dose limits are the standard limits below which the total exposure
(13)
to all radiation sources under management is to be controlled.
During normal operating conditions, the exposure from sources or
practices should be restricted by the application of the dose limitation
system which includes justification of the practice, optimization of
radiation protection and establishment of the annual dose equivalent
limits. (16)
Accordingly, the justification is to be made from three viewpoints (the
fact that radiation use in medicine is more beneficial than harmful to
patients; application of specific methods to patients exhibiting specific
symptoms; and application of methods customized for respective
patients), and doses are to be optimized by applying diagnostic reference
levels, etc. (13)
2.1.2 As Low As Reasonably Achievable (ALARA)
Principle:
ALARA is an acronym formed from the phrase “As Low as Reasonably
Achievable.” The phrase refers to a principle of keeping radiation doses
and releases of radioactive materials to the environment as low as can be
achieved, based on technologic and economic considerations. (17)
The ALARA principle states that the radiation exposures should be
limited to a minimum level since the Ionizing radiation may produce
biological effects in the exposed person. There shall be no intentional
exposure to radiation unless there are benefits to either the individual or
society. (18)
Therefore, this philosophy, as low as reasonably achievable, should be a
main part of every health care facility's personnel radiation control

program. In addition, because no dose limits have been established for

the amount of radiation that patients may receive for individual imaging
procedures, the ALARA philosophy should be established and
maintained and must show that we have considered reasonable actions
(19)
that will reduce doses to patients and personnel below required limits.
The following mitigation methods can often be a practical and effective
means of minimizing external radiation hazards.
2.1.2.1 Minimize Time:
Reduction of time of exposure can directly reduce radiation exposure. (18)
The dose to an individual is directly related to the duration of radiation
exposure. If the time during which one is exposed to radiation is doubled,
the exposure will be doubled, as follows:
Expusre=Exposure time× Exposure rate
During radiography, the time of exposure is kept to a minimum to reduce
motion blur. (19)
2.1.2.2 Maximize Distance:
Increasing the distance between you and the radiation source will reduce
exposure by the square of the distance. (18)
As the distance between the source of radiation and the person increases,
radiation exposure decreases rapidly. This decrease in exposure is
calculated using the inverse square law. (19)
Most radiation sources are point sources. The x-ray tube target, for
example, is a point source of radiation. The scattered radiation generated
in a patient appears, however, to come not from a point source but rather
from an extended area source. As a rule of thumb, even an extended
source can be considered a point source at sufficient distance. Earlier,
when the square law was used to calculate exposure in radiographic
technique, the following formula may have been used:
Old expusre New distance squared
=
Old distance Old distance squared
In this case, the exposure from the source (the x-ray tube) was varied so
that the optical density of the film (OD) would remain constant. When the
inverse square law is used in calculations for radiation protection, it is
usual to calculate the dose received at a point with the radiation from the
tube as the constant. (19)
Thus the above formula becomes:
New exposure New distance squared
=
Old exposure Old distance squared
Note that the “distance” part of the equation is reversed. (19)
In radiography, the distance from radiation source to patient usually is
fixed by the type of examination, and the radiologic technologist is
positioned behind a protective barrier. (19)
2.1.2.3 Use Shielding:
Shielding a radiation source often involves additional economic
considerations. It is not necessary to shield every source. However,
shielding can effectively reduce radiation doses in some situations. (18)
Positioning shielding between the radiation source and exposed persons
greatly reduces the level of radiation exposure. Shielding used in
diagnostic radiology usually consists of lead, although conventional
building materials also are used. (19)
The amount that a protective barrier reduces radiation intensity can be
estimated if the half-value layer (HVL) or the tenth-value layer (TVL) of
the barrier material is known. The HVL is the width of a material
required to reduce the aor kerma of an X-ray or gamma ray to half of its
original value, The TVL is the thickness of absorber that reduces the
radiation intensity to one-tenth its original value. (19)
(Table 2-1): shows approximate HVLs and TVLs for lead and concrete
for diagnostic x-ray beams between 40 and 150 kVp.
s h ielding
1 TVL = 3.3 HVL
Table 2-1 Approximate Half-Value and
Tenth- Value Layers of Lead and
Concrete at Various Tube
Potentials
HVL HVL
Potential Tube Lead Concrete Lead Concrete
(mm) (cm) (mm) (cm)
40 Kvp 0.03 0.33 0.06 1.0
60 Kvp 0.11 0.64 0.34 2.2
80 Kvp 0.19 1.1 0.64 3.6
100 Kvp 0.24 1.5 0.80 5.1
125Kvp 0.27 2.0 0.90 6.4
150 Kvp 0.28 2.2 0.95 7.1

2.1.2.4 Responsibility for Maintaining ALARA in the Medical

Industry
Both employers of radiation workers and the workers themselves have a
responsibility for radiation safety in the medical industry. For the welfare
of patients and the workers, facilities providing imaging services must
have an effective radiation safety program. (18)
A written policy statement describing this program and identifying the
commitment of management to keeping all radiation exposure ALARA
must be available to all employees in the workplace. (18)
2.1.3 Occupational Radiation:
Occupational exposure is the exposure of workers incurred during the
course of their work, regardless of the exposure situation. (20)
The term ‘occupational exposure’ has been used by the International
Labour Office (ILO) to refer to the exposure of a worker during work
hours. The International Atomic Energy Agency (IAEA) provides a more
limited definition of occupational exposure: ‘All exposures of workers
incurred in the course of their work with the exception of exposures
excluded from the Standards and exposures from practices or sources
exempted by the Standards. (21)
As per Activities of Atomic Energy Regulatory Board (AERB)
guidelines, the annual dose limit for an occupational worker is 30 mSv,
with the condition that it should not exceed 100 mSv in a span of five
years. (22)
The radiation dose to radiation medicine workers could be high in some
applications, and could even result in deterministic effects if appropriate
measures for occupational radiation protection are not implemented. (4)
Interventional radiology procedures tend to be complex and are
performed on patients who can be quite ill. As a consequence, more staff
will be needed in an interventional room to attend to the patients’
individual clinical needs. Not only will more staff be exposed during
interventional procedures, they will also stand close to the patient where
dose rates from radiation scattered by the patient are higher. (8)
Exposures of workers in conventional radiology, both radiodiagnosis and
radiotherapy, are generally well controlled. There are, however, new
areas of medical practice, especially interventional radiology, in which
very high exposures are incurred. Ensuring that sufficient attention is paid
to the control and reduction of such exposures requires continued efforts
in post-graduate education and in awareness raising of the medical
professionals involved. The participation of health physicists in the
implementation of optimization programmes in interventional radiology
is strongly recommended.(20)
On the topic of standards for radiation protection, the feeling was that the
standards developed at the international level now in place are generally
satisfactory as a framework for the control of occupational exposures in
developed and developing countries. (22)
In developed countries, exposure of workers in radiotherapy and X ray
diagnostics has been progressively reduced over the last decade and has
reached the level whereby annual doses to an overwhelming majority of
the personnel are lower than the current dose limits. It is well understood
that the magnitude of occupational exposure in these two specialties has
reached a level that is consistent, on the basis of common sense, with the
concept of optimized protection. (22)
2.1.3.1 Occupational Radiation Dose Management:
Radiation is energy that is emitted in the form of waves or particles and
transferred via a medium or space. It can come from both natural and
manmade sources. Ionizing and non-ionizing radiation are the two types
of radiation. Ionizing radiation is defined as radiation with the highest
energy and penetration power, such as x-rays. Non-ionizing radiation, on
the other hand, is a form of radiation with less energy than ionizing
radiation. It is used in ultrasound that applies high frequency sound
waves. It is also used in magnetic resonance imaging (MRI) scanners that
uses radiofrequency and does not induce ionization. (23)
The International Commission on Radiological Protection (ICRP)
expressed occupational radiation dose in terms of effective dose and
equivalent dose. The effective dose is the dose to the whole body, while
the equivalent dose is the dose to the skin, extremities, and lens of the
eyes. The annual effective dose limit set by ICRP is 20 mSv, with a limit
of 100 mSv in five years. The equivalent dose limit for skin and
extremities is 500 mSv, and 20 mSv for the eye lenses (IAEA, 1996;
ICRP, 1991, 2012). (23)
Radiation dose is measured in units of Gr t (rads). Radiation exposure is
measured in Gya (roentgens). When the exposure is to radiologic
technologists and radiologists, the proper unit is the (rem). (8)
The Sv is the unit of effective dose; it is used for radiation protection
purposes. Effective dose is the equivalent whole-body dose. Although
exposure, dose, and effective dose have precise and different meanings,
they often are used interchangeably in radiology because they have
approximately the same numeric value following whole-body exposure.
(8)

According to the International Commission on Radiological Protection’s

(ICRP) recommendations, occupational radiation exposure can be defined
using effective dose and equivalent dose . Workers’ annual effective dose
limits should not exceed 20 millisieverts (mSv) averaged over five years
(100 mSv in five years), with a stipulation that no single year’s exposure
should exceed 50 mSv. (24)
The average annual radiation exposure dose from all sources for the
global population is roughly 3 mSv per person per year, with medical use
of radiation accounting for 19.7% (0.6 mSv) of the annual dose from all
sources. Medical uses of radiation account for more than 99.9% of all
man-made radiation exposure, with billions of procedures performed each
year in all parts of the world. According to recent estimates from the
United Nations Scientific Committee on the Effects of Atomic Radiation
(UNSCEAR), there are four billion x-ray examinations performed
worldwide each year. (24)
In comparison to developed countries, the number of diagnostic and
therapeutic x-ray procedures in low-income countries, such as Sub-
Saharan Africa, is limited. However, for a variety of reasons, the amount
of occupational radiation exposure dosage is higher in developing
countries. Perhaps the most important reasons are a lack of skill and
experience, a lack of radiation protection education and training, a lack of
radiation protective barriers, poor machine quality (the machines are
either old, conventional machines or donated used machines), a lack of
equipment calibration, and a lack of machine spare parts. (25)
2.1.3.2 Radiation Dose Limits:
A continuing effort of health physicists has been the description and
identification of occupational dose limits. For many years, a maximum
permissible dose (MPD) was specified. The MPD was the dose of
radiation that would be expected to produce no significant radiation
effects. (8)
At radiation doses below the MPD, no responses should occur. At the
level of the MPD, the risk is not zero, but it is small—lower than the risk
associated with other occupations and reasonable in light of the benefits
derived. The concept of MPD is now obsolete and has been replaced by
dose limits (DLs). (8)
Occupational exposure is described as dose equivalent in units of
millisievert (millirem). DLs are specified as effective dose (E). (8)
The effective dose (E) was created to provide a dose quantity that was
related to the probability of health detriment due to stochastic effects
from exposure to low doses of ionizing radiation. (26)

The effective dose is the mean absorbed dose from a uniform whole-body
irradiation that results in the same total radiation detriment as from the
nonuniform, partial-body irradiation in question. (27)

The effective dose is calculated as the weighted average of the mean

absorbed dose to the various body organs and tissues, where the
weighting factor is the radiation detriment for a given organ from a
whole-body irradiation! as a fraction of the total

radiation detriment. (27)

Effective Dose (E)
¿ Radiation weighting factor (Wr)×Tissue weighting factor (Wt )× Absorbed dose
For our purposes, effective dose (E) is the quantity of importance. It is
expressed in mSv (mrem) and forms the basis for our DLs. The radiation
weighting factor (Wr) is equal to 1 for the types of radiation used in
medicine. The value of Wr for other types of radiation depends on the
linear energy transfer (LET) of that radiation. The tissue weighting factor
(Wt) accounts for the relative radiosensitivity of various tissues and
organs. Tissues with a higher value of Wt are more radiosensitive. (8)
Table 2-2: Occupational exposure limits (ICRP 75, 1997)2
Application Dose limits
50 mSv per year (or 1mSv per
Effective dose (whole body), Hp week)
(10) 20 mSv per year (or 0.4 mSv per
week) averaged over defined
periods of five years
Annual equivalent dose to lens of 150 mSv
 the eye, Hp (3)
Annual equivalent dose to the skin, 500 mSv
Hp (0.07)
Annual equivalent dose to hands 500 mSv
and feet
2.1.3.3 Reduction Of Occupational Radiation Exposure:
The radiologic technologist can do much to minimize occupational
radiation exposure. Most exposure control procedures do not require
sophisticated equipment or especially rigorous training, but simply a
conscientious attitude regarding the performance of assigned duties. (8)
In diagnostic radiology, at least 95% of the radiologic technologist’s
occupational radiation exposure comes from fluoroscopy and mobile
radiography. Attention to the cardinal principles of radiation protection
(time, distance, and shielding) and ALARA are the most important
aspects of occupational radiation control. (8)
The radiologic technologist should wear a protective apron during all
mobile examinations and should maintain maximum distance from the
source. The primary beam should never be pointed at the radiologic
technologist or other nearby personnel. (8)
2.1.3.3.1 Occupational Radiation Monitoring:
Radiation monitoring of staff in X-ray facilities improves awareness of
radiation protection and ensures adequate protection of the staff and the
public from medical exposure to radiation which comprises the greatest
amount of radiation exposure to man. (29)
Each worker who is expected to receive more than 10% of the applicable
annual dose limit (NRC) or more than 25% of the quarterly dose limit
(OSHA) is required to wear one or more dosimeters. (30)
For individual monitoring of occupational exposures to external radiation,
the operational quantity recommended by ICRP is the personal dose
equivalent (Hp (d)) whose unit of measure is the Sievert (Sv). (31)
Determining the quantity of radiation they receive requires a program of
occupational radiation monitoring. Occupational radiation monitoring
refers to procedures instituted to estimate the amount of radiation
received by individuals who work in a radiation environment. (8)
The occupational radiation monitor simply measures the quantity of
radiation to which the monitor was exposed; therefore, it is simply an
indicator of exposure to the wearer. Basically, three types of personnel
monitors are used in diagnostic radiology: film badges,
thermoluminescence dosimeters (TLDs), and optically stimulated
luminescence dosimeters (OSLs). (8)
2.1.3.3.1.1 Film Badge:
Film badges came into general use during the 1940s and have been used
widely in diagnostic radiology ever since. (8)
Personal dosimeter film badge are widely used for X-rays, gamma-rays
and alpha particles for measuring and recording radiation exposure (fig 2-
2). (32)

Fig (2-2): Disassembled film badge, demonstrating badge components:

plastic holder, metal filters, and film packet.
The detector is a photographic film, as the name implies, which sensitive
and must be produce on a monthly. The film is sealed in a light- and
vapor-resistance envelope to avoid any effect of illumination, moisture,
or chemical vapor on the film. (32)
The higher the radiation exposure, the darker the film becomes. The
film's blackness is linear proportional to the dosage and doses can be
tested up to around 10 Gy. A dosimeter is a film tag, which is worn by a
person for monitoring the surface of the body, and it records the received
exposure dose. (32)
2.1.3.3.1.2 Thermoluminescencet Dosimeters:
Theromluminescencet dosimeter (TLD) is a passive radiation detection
device that is used for personal dose monitoring or to measure patient
dose. (33)
TLD is an inert radiation detector device for monitoring personal
exposure and for measurement of patient exposure. The dosage can be as
low as 1 milirerm for a long duration (normally 3 months or less), but the
low dose capacity is almost identical to that of a film badge under daily
conditions. (32)
TLD badge parts are fitted with plastic, nickel-plated TLD aluminum
cards, discs of thermoiuminescent content, and normally doped with
dysprosium-activated calcium sulfide (CaSO4:Dy) or lithium fluoride
(LiF) (Fig2-3). (32)
Among different technologies, thermoluminescent dosimeters (TLDs) are
the most used for medical workers monitoring. (31)
The TLD occupational radiation monitor offers several advantages over
film. It is more sensitive and more accurate than a film badge monitor.
Properly calibrated TLD monitors can measure exposure as low as 50
µGya (5 mR).(8)
 Fig (2-3): Thermoluminescence dosimeters are available as chips, discs,
rods, an powder. These are used for area and environmental radiation
monitoring, and especially for occupational radiation monitoring.
(Courtesy Bicron).
2.1.3.3.1.3 Optically Stimulated Luminescence:.
Optically stimulated luminescence dosimeters (OSL) are passive
radiation detection devices used for personal dose monitoring (Fig2-4).
(33)

OSL dosimeter are designed to provide a very high level of sensitivity to

X-rays or gamma-ray photon energy from 5 Kv to greater than 40 Mev,
giving accurate readings as low as 1 millirem. (32)
Unlike thermoluminescent dosimeter (TLD). OSL does not need heating
for the reading of radiation dose. OSL dosimeter can be read multip;e
times and stored foe several years. (34)
OSL dosimeters are worn and handled just as film badges and TLDs are,
and they are approximately the same size. OSL dosimeters have one
advantage over TLDs. They are more sensitive, measuring as low as 10
µGya (1 mR). (8)
 Fig(2-4): Optically Stimulated Luminescence (OSL).
2.1.3.3.1.4 Lens Dose-Monitoring Devices:
Among different technologies, thermoluminescent dosimeters (TLDs) are
the most used for medical workers monitoring. There are different types
on market such as the EYE D™ dosimeter (Fig2-5) which can be worn
on a narrow headband adjacent to the eye, the DOSIRIS™ dosimeter
which is mounted on an adjustable headset, or the VISION™ dosimeter
which may be installed in front or behind, in horizontal or vertical
(31)
orientation on most personal protective equipment (PPE).

Fig (2-5): Different passive dosimeters: a the TLD EYE-D™ dosimeter, b

the DOSIRIS™ dosimeter, c the VISION™ dosimeter (d) and an OSL
dosimeter.
2.1.3.3.2 Protective Apparel:
The Lead Apron is a piece of Personal Protective Equipment (PPE) that
protects its user against the effects of ionizing radiation which is common
in things such as the X-ray. (34)
The first lead apron was invented by Antoine Béclère in 1906, who
introduced safety equipment like, lead aprons and lead rubber gloves. (35)
Their specific function is to provide shielding against secondary
radiation. Practically, lead rubber aprons are used during a variety of
diagnostic imaging procedures including angiography, fluoroscopy,
mobiles and theatre procedures and are designed to shield approximately
75% of radiosensitive red bone marrow. They may reduce the dose of
radiation received by over 90% (85% - 99%) depending on the energy of
the X-rays and the lead equivalent thickness of the apron. (36)
The medical Guidance note issued by the Institute Of Physics And
Engineering a Medicine (IPEM) regarding protective clothing states that
"Body aprons should be available with a protective equivalent of not less
than 0.25mm lead for x-rays of 100kVand not less than 0.35mm lead for
x-rays over 100kV''. (36)
Standard lead apron must provide at least 0.5 mm of lead or equivalent
structural barriers (ie, a 0.2 mm lead equivalent ¼ 1.2 mm of steel, 2.5
mm of glass, 5.9 mm of gypsum, 33 mm of wood). Lead aprons of 0.5
mm thickness have been shown to shield approximately 99% of potential
radiation dose. Lead apron must cover the front of the body from the
throat to within 10 cm of the knees, as well as the sides of the body from
the shoulder to below the buttocks. (37)
The current aprons made of lead impregnated with polyvinyl chloride
(PVC), rubber or emulsion polymers, stabilizers and pigments have been
used for almost 100 years to provide protection against radiation in
hospitals. (36)
Care of the lead apparel is must to keep the lead integrity. Frequent
falling, dropping, piling, improperly storing can lead to internal fracture
of the lead layer, affecting the integrity and protective capability. (37)
Hence proper storage and checking is required for its optimum use. Lead
apron, side shields, thyroid shields, gloves shields and other protective
apparel should either be kept flat or on hangers in properly designed racks
or to prevent defects such as internal cracks and tears. (37)
2.1.4 Patient Radiation Dose Management:
Patient dose from diagnostic x-rays usually is reported in one of three
ways. Exposure to the entrance surface, or entrance skin dose (ESD), is
reported most often because it is easy to measure. (8)
The gonadal dose is important because of possible genetic responses to
medical x-ray exposure. The dose to the gonads is not difficult to measure
or estimate. The dose to the bone marrow is important because bone
marrow is the target organ believed responsible for radiation-induced
leukemia. Bone marrow dose cannot be measured directly; it is estimated
from ESD. (8)
Table 2-3 presents some representative values of ESD and gonadal dose
for various x-ray examinations.
Table 2-3 Representative Radiation Quantities From Various
Diagnostic X-ray Procedures
Examination Technique Entrance Mean Gonad Dose
(kVp/mAs) Skin Dose Marrow (mGyt)
(mGyt) Dose
(mGyt)
Skull 76/52 2.0 0.10 <1
Chest 110/3 0.1 0.02 <1
Cervical 70/40 1.5 0.10 <1
spine
Lumbar spine 72/60 3.0 0.60 2.25
 Abdomen 74/60 4.0 0.30 1.25
Pelvis 70/50 1.5 0.20 1.50
Extremity 60/5 0.5 0.02 <1
2.1.4.1 Reduction Of Unnecessary Patient Radiation Dose:
2.1.4.1.1 Repeat Examinations:
One area of unnecessary radiation exposure that the radiologic
technologist can influence is that of repeat examinations. The frequency
of repeat examinations has been estimated variously to range as high as
10% of all examinations. In the typical busy hospital facility, the rate of
repeat examinations should not normally exceed 5%. Examinations with
the highest repeat rates include lumbarspine, thoracic spine, chest and
abdomen. (8)
Some repeat examinations are performed because of equipment
malfunction. However, most are caused by radiologic technologist error.
Studies of causes of repeat examinations have shown that improper
positioning and poor radiographic technique resulting in an image that is
too light or too dark are primarily responsible for repeats. Motion and
improper collimation are responsible for some repeats. Infrequent errors
that contribute to repeat examinations include dirty screens, use of
improperly loaded cassettes, light leaks, chemical fog, artifacts caused by
a dirty processor, wrong projection, improper patient preparation, grid
errors, and multiple exposures.(8)
2.1.4.1.2 Specific Area Shielding:
It is recommended to protect the thyroid, breast and gonads in children
and young adults. Lead apron should be placed to protect the gonads from
primary beam radiation exposure; lead collar should be provided to cover
patient's neck and thorax to shield thyroid and breast. (36)
It is important to decide the placement of shield on front of patient,
beneath or all around based on the direction of the tube during the
procedure. It is a common to think that in all cases the lead shield should
be placed over the top of their gonads which do not provide the
protection. It is important to consider shielding the patient before
preparation and draping. (36)
Areas of breast tissue may be shielded by using a clear lead shadow
shield. This shielding is of vital importance in providing protection
during juvenile scoliosis examinations.
Two types of specific area shielding devices are used: the contact shield
(Fig2-6) and the shadow shield(Fig2-7). (8)

Fig(2-6): Examples of useful contact gonad shields, which can be a piece

of vinyl lead (A) or shaped (B).

Fig(2-7): A, Shadow shield. B, Shadow shield suspended above the

beam-defining system casts a shadow over the gonads.
2.2 The design of the radiology department:
The department of diagnostic and interventional radiology is one of the
main division in the medical clinic responsible for diagnostic illnesses
and tumors and aiding medical procedures that requires radiography. The
department requires significant focus during its design so that it can
guarantee the necessary proficiency, staff satisfactions, work process,
radiation security, image qualities and etc. (38)
The past 10 years have witnessed significant progress in diagnostic
imaging through the digital transformation, the evolution of imaging
technologies, and future functional requirements. Designers and
architects who specialize in healthcare must provide a modern, adaptable
built environment that provides the best care for the patient. The
following guidelines are presented through three main considerations:
planning, design, and technical considerations. (39)
2.2.1 Planning Considerations:
The planning phase is the first and most important step to put the basic
strategies. (39)
The planning and design of radiology and imaging services department
hinges on a number of factors: site, floor loading, size of the rooms
needed, traffic pattern inside the building, heating and cooling, electrical
and water supply, and importantly, shielding requirement in the facility to
comply with the statutory regulations. (40)
2.2.1.1 Department location:
The department should be located in such a way that it is easily accessible
to inpatients, out patients and emergency patients. It is preferred to have
the services far away from heavy traffic areas in the building to minimize
exposure to non-radiation workers. Ground floor is most suitable to
accommodate heavy machinery and their scaffoldings. (40)
Imaging facilities are frequently located on the ground floor of hospitals.
Floor shielding is not necessary if there are no occupied basements or
under floor service corridors, provided that the shielded wall extends the
full way to the ground and does not end at a false floor level. Walls
extending beneath false floors shall be appropriately shielded to protect
the adjacent rooms. If there is occupancy or services beneath the X-ray
facility or if it is located on an upper level, floor shielding will normally
be required. In addition, it is likely that the floor will be required to
provide protection against the primary beam. (41)
Poured concrete is commonly used in floor or ceiling slabs. A thickness
of 150 mm is needed for load bearing and this will provide sufficient
protection for many ceilings and floors provided that it is solid
throughout. Waffle type slabs are widely used for floors and ceilings in
buildings as illustrated in (Fig2-8). They typically have a maximum
thickness of 150 mm that reduces to 75 mm at the thinnest part. Thus
when waffle type construction is used in the floor or ceiling of an X-ray
room, additional shielding is generally necessary. This may be provided
by lead plywood to the top or underside. The additional shielding must
provide sufficient overlap with the waffle slab and perforations made
during fixing must be protected. (41)
It can be either on the basement, ground floor, or both for the vertical
location. While the horizontal location can be either centralized or
decentralized configurations. (39)
In the case of X-ray rooms located on the top of a building where other
higher level buildings are in the vicinity, the possible need for additional
shielding must be taken into account. (41)
 Fig(2-8): Waffle type ceiling
2.2.1.2 Patient Waiting Area:
According to western data, approximately 80-85% patients are
ambulatory and 15-20% are either on wheel chair or on stretcher, 5-10%
are pediatric group of patients and suggested space requirement is 1.3 sq.
m per patient visit. Depending on the scale of the hospital, waiting area
can be centralized with a common reception and registration counter for
radiology and imaging services or decentralized with sub waiting areas.
(39)

2.2.1.3 Radiography rooms:

The location, structural design and equipment layout of X-ray rooms
must be carefully considered from a radiation protection perspective. This
is easier when X-ray facilities are not designed as stand-alone rooms and
are planned as part of an integrated radiology/imaging department with its
supporting areas and services. Planning the room layouts should start as
early as possible in the design process and be based on inputs from a team
including architects, engineers, hospital management, radiologists,
radiographers, other consultant medical staff such as cardiologists or
vascular surgeons where relevant, and once identified, the equipment
supplier(s). (41)
X-ray rooms should be of a size that allows unimpeded access and ease of
movement around the equipment, the patient table and the operator’s
console. The size of the room will vary greatly depending on the modality
and the cost of space. (41)
The boundaries to all occupied areas (walls, doors, doorframes, floor,
ceiling, windows, window frames and the protective viewing screen)
must be shielded appropriately. Generally this requirement will be met by
2 mm of lead, or its equivalent with other material. (41)
The room has been designed with a number of features in mind. There is
good access through the patient doors, to allow patients on trolleys to be
brought into the room and ensure ease of access to the table. The staff
entrance is placed so that the door to the corridor is behind the protective
barrier. This protects both staff entering this area and the corridor if the
door is inadvertently opened. The protective barrier is composed of a
lead-ply or equivalent lower section and a lead glass upper section which
allows a panoramic view of the room. A protective screen length of 2-2.5
m with a 0.6-1.0 m wing is normally adequate. However, how this fits
with the general room design must be considered. The chest stand, in this
example, has been positioned to minimize the amount of scattered
radiation that can enter the operator’s console area. (41)
Patient changing facilities must be provided and should be close to a
general X-ray room. Cubicles may be designed as individual changing
rooms, which open directly into the X-ray room. This will allow for
changing arrangements consistent with good radiation protection practice,
greater privacy, security and perhaps faster patient throughput. The main
alternative is to group the cubicles together close to the X-ray room but
not adjoining it, and allow for a sub-waiting area from which the changed
patients are escorted to the X-ray room (NHS, 2001). The advantage of
(41)
this design is that there are less access points into the X-ray room.
Cubicle doors leading into the X-ray room must provide adequate
radiation protection and the lock should be controlled from the X-ray
room to prevent inadvertent access. These considerations on cubicles
apply to many of the other room types dealt with in this section. (41)
2.2.1.3 Space:
The size of X-my rooms will depend upon the capacity and type of
equipment to be installed (Whether 500 MA or 200 MA). (40)
An X-ray room should approximately be 40 sq.m with its long axis
minimum of 6.7m. depth not less than 5.8m and height 3.3m
approximately. Door opening should be at least 1.3m wide and there
should preferably be mazes between staff corridor and X-ray rooms to
prevent radiation exposure. A lead glass window or screen is essential
between X-ray machine and control panel to protect staff from radiation.
Careful attention needs to be given to the placement of the x ray tube,
couch, control console and chest stand in the x ray room. (40)
2.2.1.4 Walls
The minimum secondary wall thickness of a general purpose radiography
and fluoroscopy rooms should be 230 mm solid cement block or
equivalent, whereas that of the primary shall be 320 mm of solid cement
block or equivalent. (40)
As an alternative to using concrete, wall shielding may be provided using
panels of lead plasterboard or lead plywood. The internal walls of many
modern buildings are composed of plasterboard attached to both sides of
metal or wooden framing. Lead plywood or plasterboard may be used on
one side of the internal framing to achieve the required shielding. Ideally
it should be used on the side which will require the least perforation. Lead
plasterboard is less robust than lead plywood during handling; however it
leaves a smooth finish for decorating. (41)
2.2.1.5 Doors
Doors should be of solid construction with the lead bonded on both sides
by wood or a suitable alternate protective material. (40)
The room should be designed so that the uninterrupted X-ray beam will
not normally be directed towards doors. (40)
There may be several doors leading to an X-ray room including the
patient door, the staff door, and doors to changing cubicles or possibly to
a patient toilet. The room should be designed so that the uninterrupted
X-ray beam will not normally be directed towards doors, windows, or the
operator’s console. Even with this provision the door and doorframe must
be shielded against scatter. The shielding must be uninterrupted between
double doors, between the door and frame, and between the doorframe
and the adjoining wall. Generally the minimum overlap is 1.5 cm. In the
case of a concrete or brick wall, the shielding should overlap the
doorframe and wall by a distance at least equivalent to the thickness of
the concrete or brick in the wall (WHO, 1974). Sliding doors are
attractive for saving space but can become difficult and tiring to move,
which results in their not being closed properly. Patient doors should be
wide enough to allow beds and trolleys to pass through. They should
open into the controlled area to provide protection should a person enter
the room inadvertently (NHS, 2001). (41)
Doors should be of solid construction with the lead bonded on both sides
by wood or a suitable alternate protective material (Fig:2-9). The
shielding must run the entire length and width of the door down to a few
mm from the floor, and continue on the underside. Doors may include
lead glass windows. The shielding in the window, window frame and
door must be effectively uninterrupted and sufficiently overlapped as
indicated in Ap. Doors in rooms such as shielded operating theatres may
contain ventilation panels. These must also be appropriately protected.
Doors and windows should be marked with their lead equivalent
thicknesses. (41)

Fig(2-9): Lead doors, Radiation warning lights and signs

Access through doors must be controlled by the use of appropriate lights
and signs, unless the entrance is locked during exposures (as may be the
case with doors leading to/from changing cubicles or toilets). Warning
lights should preferably be located beside the door at eye level (MDGN,
2002). They should be two stage devices, with a yellow ‘Controlled Area’
warning light illuminating when power is supplied to the unit and a red
‘Do Not Enter’ warning illuminating on preparing the X-ray tube for an
exposure. (41)
Door interlocks, which interrupt X-ray production, are not desirable since
they may disrupt patient procedures and this can be both dangerous and
result in unnecessary repeat examinations. (41)
2.2.1.6 Windows:
Unshielded windows must be at a height of greater than 2 m from the
outside ground. Windows at a height less than the 2 m may be shielded
by lead glass or lead acrylic. These should be provided in the form of
double-glazing, with plate glass on the outside as lead glass and lead
acrylic may be easily damaged and lead glass must be kept dry. Lead
glass or lead acrylic windows should be marked with the lead equivalent
thickness. (40)
The issue of shielding of X-ray room windows must be referred to the
RPA as the majority of these windows may require shielding. For general
rooms, the lead equivalence of the window required may be 2 mm at 150
kV depending on the workload, the occupancy outside, and the distance
to the nearest occupied area, although windows of 3-4 mm lead
equivalence at 150 kV. In all cases the actual amount of shielding
required should be based on the RPA’s advice. (41)
2.2.1.7 Staff Areas in X-ray Room:
A protective screen, or shielded console area, must be provided for staff
at the control panel in an X-ray room. Protective screens are typically
custom designed and the location, size and shape will involve
collaboration between the equipment manufacturer, the user and the RPA.
The final design should be approved by the RPA before installation. The
screen should ideally be located in a position adjoining the staff entrance
and should be angulated so that that primary radiation and first scatter
cannot enter directly the area behind it. In addition, there should not be an
unprotected direct line of sight from the patient or X-ray tube to the
operator behind the screen or to a loaded cassette or CR plate inside the
control booth (Fig2-9). (41)
 Fig (2-9) : General X-ray room with chest stand
2.2.1.10 Darkroom Pass Hatches:
When the door of the darkroom is shut, there must not be any light
coming into the darkroom. To check this, go into the darkroom, close the
door, and stay inside without light for 10 minutes. (Set the processing
timer to make sure you have really spent 10 minutes in the dark.) Then
look around carefully for any light entering the room through holes or
cracks; cover these holes, thus blocking out the light. If the darkroom has
a "light-trap" instead of a door, make sure that light does not leak in
through the trap. Check the darkroom at different times of the day, to
allow for changes in the angle of the sun's rays. (42)
The darkroom should be clean at all times. Both the bench (or table) and
the floor must be kept clean and dry. There should be no dust, dirt, or
moisture in the area where the X-ray films and cassettes are handled. The
floor should be wiped with a damp mop or cloth every week. The tanks
containing the processing chemicals should also be kept very clean, and
should be covered when not actually in use. The covers must be put on
the tanks whenever you leave the darkroom, even if only for a short time.
(42)

Provision should be made for film pass hatch between the x-ray room and
dark room if a darkroom is required. The pass hatch must be lead-lined
(at least 0.8 mm lead equivalence for mammography; 1.0 mm lead
equivalence for dental, general radiography and fluoroscopy) with the
suitable supports and overlaps. The shielding must be on the x-ray room
side of the pass hatch. (40)
The lights used in the darkroom may be green, orange, yellow, or brown.
Check the box containing the X-ray film: the manufacturer prints on the
box the details of the colour filter needed for processing the film. All
safelights should be at least 1.3 m (4ft) above the working bench and
should preferably be pointing upwards. The bulbs used in the safelights
should never exceed 25 watts (25 W).
2.2.1.11 Ventilation:
Because the electronics modules and scanners generate heat during
operation, cooling is essential for the equipment and an efficient cooling
and ventilation system must be installed. (40)
The purpose of the primary ventilation system in a facility is to provide
fresh air to workplaces to remove airborne contaminants generated by the
operations. Careful attention should be given to the design of the
ventilation network, including the calculation and verification of rates and
velocities of air flow, to ensure that it is adequate for controlling airborne
contamination. (43)
2.2.1.12 IT Systems In Radiology:
The two major types of IT systems developed to take care of the digital
workflow in a radiology department are Radiology Information Systems
and Picture Archive and Communication Systems (PACS). (39)
PACS is a computerized means of replacing the roles of conventional
radiological film: images are acquired, stored, transmitted, and displayed
digitally. When such a system is installed throughout the hospital, a
filmless clinical environment results. (44)
Were the replacement of conventional x ray film the only role of PACS,
then it would be an unjustifiably expensive and highly complex way of
achieving this goal. The main advantage a PACS offer is the
improvement in efficiency resulting from electronic data handling: Once
an image has been acquired onto PACS it cannot be lost, stolen, or
misfiled. (Many hospitals report that 20% of films are missing when
required, creating a serious practical problem.), The PACS database
ensures that all images are automatically grouped into the correct
examination, are chronologically ordered, correctly orientated and
labeled, and can be easily retrieved using a variety of criteria (for
example, name, hospital number, date, referring clinician, etc), Working
with soft copy images on monitors allows the full gamut of computer
tools to be used to manipulate and post-process the images and The
numerous PACS terminals throughout the hospital allow simultaneous
multiplication viewing of the same image, if desired, conventional film
can only physically exist in one place at any one time. (44)
2.2.2 Design Considerations:
Good design meets the needs of different users, enhancing interactions
between them and technology, and integrating form with function. The
design process includes 3 stages, which are : A- Concept design: A
sequence of block diagrams. B- Schematic design: Block diagrams are
evolved into single-line or double-line graphics C- Design development:
Developing the interior and exterior of the schematic design. (39)
The design of the diagnostic radiology department consists of main
architectural components that make up each radiology suite within the
department such as procedure room, control area, digital image
management area, reading room, and support spaces (dressing areas,
toilets, and waiting areas). These components can be as a part of the
procedure room for a single radiology room. However, they can be shared
by more than one room for suite radiology as shown in (Fig: 2-12). (39)

Fig (2-12): The main component of the radiology department for different
rooms: (a) single radiography room, (b) CT suite.
2.2.3 Technical Considerations:
Many technical considerations must be considered during the planning
and design phases such as: 1.Structural: Determining the construction
system is based on the requirements for the size, weight, and radiology
equipment support according to the equipment manufacturer,
2.Architectural: All finishing for architectural elements including floors,
ceilings, walls, and doors should be coordinated with the equipment
manufacturer, 3.Heating, Ventilating and Air Conditioning (HVAC) :
HVAC installations depend on the number of people and the AC load.
The design of the air distribution system shall be in accordance with the
HVAC Design Manual criteria of CDC and HICPAC (the Healthcare
Infection Control Practices Advisory Committee), 4.Plumbing: All
plumbing services that include water, waste, and medical gas systems
must be planned and designed according to ACR guidelines, 5.Electrical:
Different levels of illumination should be provided. All power
installations are subject to the IEEE Recommended Practice for Powering
and Grounding Electronic Equipment, 6.Life Safety: All design
considerations are subject to the latest editions standards of the National
Fire Protection Association (NFPA) 101 “Life Safety Code”, NFPA 99,
Health Care Facilities Code, and the International Building Code and
7.Communications: Communications services include telephone, ADP,
network, Intercom, nurse-call, public address, and miscellaneous systems
such as MATV, CATV. (39)
2.3 Medical Imaging Equipment:
Equipment is the major tool of any radiology department. The quest for
improved health care services led to an increasing need for production of
radiology equipment that strikes a balance between production of high
quality diagnostic images and reduced radiation dose to patients.
Accurate diagnostic imaging using the current generation of radiological
equipment requires that they always function optimally. Advances in
technology and increased demand for quick and efficient delivery of
radiology services led to heavy reliance on computer based technology.
(45)

The technical equipment that creates the images used in radiology

depends on the respective modalities. The imaging technology most
commonly used today is conventional radiography with photographic
plates as a replacement for the analogue technique, in which a
photographic film was exposed to radiation and later developed
chemically to create the image. The photographic plate collects and
counts the radiation which passes through the patient and the result is
processed by computers to create the digital image. (46)
General radiography is a service usually provided by a Radiology
Department, either in a central department or satellite facilities. Requests
for general radiography services are performed based on protocols for
standard views of each anatomic area, modified, if needed, to suit special
requests or circumstances. (30)
Each medical facility should have a written policy for the safe use of
radiographic equipment. This policy should apply to all radiographic
equipment, whether fixed or portable. This policy should: 1.specify
required testing of the radiographic equipment by a QMP (or under a
QMPs guidance for facilities or locations where it is not practicable to
provide such staffing), 2. specify required training and credentialing of
operators and Radiological Medical Practitioners directing the operation
of radiographic equipment, and 3. specify procedures for the safe use of
the equipment, including dose management and recordkeeping. (30)
2.3.1 Equipment Design for Radiation Protection:
Measures must be taken to ensure that radiographic equipment operates
safely. Every diagnostic imaging system must have a protective tube
housing and a correctly functioning control panel. The radiographic
examination table and other devices and accessories must also be
designed to reduce the patient's radiation dose. (19)
The x-ray tube and housing assembly are quite heavy; therefore, they
require a support mechanism so the radiologic technologist can position
them . The X-RAY tube (Fig2-7) is a component of the x-ray imaging
system rarely seen by radiologic technologists. It is contained in a
protective housing and therefore is inaccessible. (48)
Protective housing guards against excessive radiation exposure and
electric shock, X-ray tubes are designed with a glass or a metal enclosure.
The x-ray tube window is an area of the glass or metal enclosure,
approximately 5 cm2, that is thin and through which the useful beam of
x-rays is emitted. Such a window allows maximum emission of x-rays
with minimum absorption. (48)
 Fig:2-7: Principal parts of the x-ray tube.
2.3.1.1Control Panel, or Console:
The control panel, or console, is where technical exposure factors such as
milliamperes (mA) and peak kilovoltage (kVp) are selected and visually
displayed. It must be located behind a suitable protective barrier that has
a radiation-absorbent window that permits observation of the patient
during any procedure. (19)
2.3.1.2 Radiographic Examination Table:
The radiographic examination table must be strong and must adequately
support the patient. Frequently, this piece of equipment has a floating
tabletop that makes it easier to maneuver the patient during an imaging
procedure. The thickness of the tabletop must be uniform, and for under
table x-ray tubes as used in fluoroscopy, the patient support surface also
should be as radiolucent as possible so that it will absorb only a minimal
amount of radiation, thereby reducing the patient's radiation dose. A
carbon fiber material is commonly used in the tabletop to meet this
requirement. (19)
2.3.1.3 X-Ray Beam Limitation Devices:
The primary x-ray beam shall be adequately collimated so that it is no
larger than the size of the image receptor being used for the examination.
With modern equipment, this is accomplished by providing the unit with
a light-localizing variable aperture rectangular collimator to adjust the
size and shape of the x-ray beam either automatically or manually. In
addition to the light-localizing variable-aperture rectangular collimator,
earlier x-ray beam limitation devices include: Aperture diaphragms (2-8),
Cones and Cylinders(Fig2-9. (19)

Fig 2-8: An aperture diaphragm.

Fig 2-9:A, Cone fashioned in the form of a flared metal tube. B, Cone
fashioned in the form of a straight cylinder.
2.3.2 Digital Systems:
Beginning in the 1990s, a transition occurred from film-screen (also
known as screen-film) radiography to digital radiography (radiography
using other image receptors). These newer image receptor technologies
include storage phosphor plates and several direct-image-capture
technologies. Radiography in which images are stored on photostimulable
phosphor plate receptors is sometimes called computed radiography
(CR). (30)
The first form of digital imaging, digital subtraction angiography, was
introduced in 1977 and put to clinical use in 1980. Computed Radiology
(CR) technology also was used in clinical practice beginning in the
1980s. (49)
In recent years, technological advances in data processing, raising the
level of specialized hospital staff, increasing patient expectations, and the
need for cost and time savings have created a huge change in healthcare,
especially the dynamic development of radiology diagnostic methods. In
fact, the main purpose of using digital systems in radiology department is
to improve the efficiency along with advancement in the diagnostic
capabilities of doctors. (50)
CR uses a storage phosphor plate. According to IMV Medical, a medical
imaging market research firm, although nearly 50% of radiology system
installed in the United State in 2015 included CR equipment, as many as
70% of sites with fixed CR system said they were planning to purchase
new DR equipment or retrofit CR equipment with DR in the coming year.
(49)

Both the direct and indirect types of DR technology measure attenuated

rays and produce electronic signals that are sent to software to rapidly
produce images in grayscale format on a monitor. The first flat-panel
detector still is common in modern system. (49)
These indirect DR detectors used amorphous silicon as a photodiode ,
measuring the light emitted from a scintillator material excited by
exposure to x-rays. Some fixed DR systems included charge-coupled-
devices (CCD) to generate an electronic signal form the emitted light.
Direct DR systems commonly use amorphous selenium as a
photoconductive material, directly converting the energy of x-ray photons
into electrical signal without the need for light as a intermediary. (49)
2.3.2.1 Dose Optimization and Image Quality:
When following the dose optimization principles, radiographers should
strive to minimize patient exposure during all radiography examination.
The appropriate use digital image receptors requires careful and
consistent attention to institutional protocol and practice standards and
can result in lower patient dose. In situation where suboptimal radiation
exposure levels have been used, the DR system still might displays a
diagnostically acceptable image. (50)
As a component of image quality, the contrast resolution of the
radiographic image depends heavily on the degree to which the exposed
anatomic region attenuates the x-ray beam. (51)
In digital radiography, the computer automatically adjusts an
overexposure to display an image of diagnostic quality. This automatic
adjustment disconnects the processes of image acquisition and display,
which can contribute to increased patient exposure because of a lack of
visual feedback for dose errors. Excessive exposure to a patient during a
DR examination does not affect image quality, except at extremely high
levels of exposure. (51)
2.3.2.2 Efficiency and Effectiveness of Digital System:
Unlike analogue films, digital radiology images are easily accessible to
patients and doctors. In fact, it can be said that the use of storage,
compression and recovery systems in medical applications is vital
because of the use of them in medical records database management,
computer-assisted diagnostics, research, teaching and medical education.
(52)

While the use of digital radiology has many benefits, including

maintaining images quality when sending to other medical centers,
eliminating contamination caused by the use of chemicals in analog
technology, requiring less radiation in digital receivers, reducing the time
from requesting images to receiving reports, improving efficiency and
productivity of radiology experts and the reduction of non-acceptance,
deletion, or recapture in the digital sector, compared to the film-based
sections. (52)

2.3.3 Safety Interlock Systems:

The purpose of a radiation safety interlock system is to prevent injury,
death, or serious overexposure from high radiation levels. The personnel
radiation safety interlocks include: radiation enclosure interlocks,
radiation activated interlocks, and some beam controlling devices such as
magnet current comparators, collimators, etc. It does not apply to
(53)
electrical safety interlocks
Beam Enclosure: Any area containing beam lines and surrounded by
walls or fences with all access points interlocked to turn off the beam.
Included are areas which do not contain beam lines but which represent
potential radiation hazards equivalent to those of beam enclosures,
Critical Devices: Any power supply, beam stop, collimator, or device
which prohibits the entry of a particle beam or otherwise prohibits the
generation of ionizing radiation. (53)
2.3.4.1 Hardware Requirements for Interlocks:
Devices for all interlocked areas should have a built-in redundancy either
in hardware or methods. Their design should be as foolproof (immune
against human error and tampering) and fail-safe (failure leading to a safe
status) as reasonably achievable. Systems which employ computer-based
monitoring or subsystems shall have a demonstrated immunity to external
tampering (hacking). (54)

There must be two independent switches or redundant methods (for

example, one pulsed optical sensor set or one mechanical and one
magnetic switch) on each door, or personnel access for all new systems
(after 1991). These shall be placed on the side of the door opposite from
the hinges except in the instance of pulsed optical sensors. The switches
must be inside the enclosure. In addition, the door must be locked, except
in areas where gates and doors are used to separate interlocked beam
enclosures and locking them would constitute a life safety code violation.
(53)

A graded approach will be used to determine the levels of redundancy

and control for areas where x-ray radiation is produced. Devices
generating up to 100 mrem/hour measured at one foot: No interlock
hardware controls to inhibit x-rays are required, Devices generating over
100 mrem/hour up to 1000 mrem/hour measured at one foot: One
method of turning off the generating device is required and Devices
generating over 1000 mrem/hour measured at one foot: Two
independent methods of turning off the generating device are required.
Opening the access door must shut off the generating devices independent
of the action of the key tree. (55)
Signs shall be conspicuously posted on the shielding blocks, hatch cover,
or lock to indicate whom to contact for lock removal and warn about
serious consequences of inadvertent removal. (54)

2.3.4 Equipment Life Cycles:

The Radiological Equipment has a definite life cycle span, resulting in
unavoidable breakdown and decrees or loss of image quality, which
renders equipment useless after a cretin time period The state of the
equipment is also affected by its utilization and maintenance(Table2-4).
(47)

Normal wear and tear of equipment, while it is being used for its intended
purpose, contributes to increasing periods of down-time. Functional
equipment failure refers to the inability of the equipment to perform its
required function within specific limits of performance, which may be
due to deterioration or breakdown of certain components that make up the
equipment. (56)
Table(2-4): Medical imaging equipment life expectancy guidance
(utilization and age related)
Device type Device life expectancy Utilization based on
based on utilization : Exam/years
HIGH-MID-LOW HIGH MID LOW
Radiology, general 10-12-14 ˃20,000 10,000- <10,000
20,000
Radiology, mobile 8-10-12 ˃6,000 3,000- <3,000
6,000
R/F Fluoroscopy 8-10-12 ˃4,000 2,000- <2,000
4,000
High 24 h/day 5days/week or 7508-h shift/ year, MID 6h/day 5
days/week or 500 8-h shift/year, LOW 8 h/day 5days/week or 250 8-h
shift/ year
In table (2-4) an examination is a defined technical investigation using a
medical imaging modality to study a body structure, system or anatomical
area that yield one or more views for diagnostic and/or therapeutic. (47)
Downtime (DT) is defined as the time during which equipment assigned
to perform a specific function is not available because of breakdown
(Elazouni & Basha, 1996). The main challenge with equipment
breakdown is how to reduce the frequency of breakdown and minimize
equipment breakdown. (56)
AS older equipment has a high risk of failure and breakdown, this may
lead to crucial delays in the diagnostic and treatment of the patient.
Moreover older equipment may might cause safety problems both for the
patient and medical staff. (47)
It is know that equipment is up to 5 years old reflect the current state of
technology and offers opportunities for economically reasonable upgrade
measures. Equipment which is between 6 to 10 years old is still fit to use
if properly maintained, but already requires replacement strategies to be
developed. Equipment older than 10 years is no longer state-of-the art
equipment and replacement is essential. It recommended that at least 60%
of the installed equipment in radiology departments should be up to 5
years old. Up to 30% should be 6-10 years old, whereas not more than
10% of equipment should be older than 10 years. (56)
2.3.5 Equipment Routine Maintenance:
Routine maintenance is a procedure to ensure equipment is kept in good
condition, and provide a long operating life. Routine maintenance may
also discover potential problems, which could cause equipment failure.
Potential problems can then be corrected, with a minimum of down time.
‘Quality control’ procedures, to ensure correct operation and calibration,
are also a part of routine maintenance. (57)
The objective of the routine maintenance is to complete operation and
function inspection, list any incorrect operation or area requiring further
attention, By means of prepared checklists, ensure all required areas are
covered. The results are to be retained in a suitable folder, In case of a
specific problem outside local resource to immediately correct, and then
request an electrician, or the service department, for assistance, Tests for
calibration of equipment. This may also be part of a quality control
programme and Cleaning of equipment. Remove pieces of sticky tape,
old sticking plaster marks etc. (57)
2.3.5.1 Routine maintenance modules:
Daily maintenance work includes careful operation, keeping the machine
room dry, good cleaning and hygiene, paying attention to safety
inspection, and other aspects. (58)
The modules are for routine maintenance of equipment. Due to the
diversity of equipment that may be in use, from very old to the latest
technology, not all of the suggestions will apply to your system. (57)
The maintenance modules are designed as individual units, however some
cross-reference is required. The reference module name, and title-page
number, is indicated in the text as required. (58)
The equipment covered in the maintenance modules includes the
following: X-ray generator, fixed installation, X-ray generator, mobile
unit, X-ray generator, capacitor discharge, X-ray generator, portable
system, X-ray tube stand, X-ray tube, Collimator, The Bucky table and
vertical Bucky, Tomography attachment, Fluoroscopy table, Fluoroscopy
TV systems and Automatic film processor. (58)
Preventing excessive force and strong vibration, especially X-ray tube,
spot film frame, etc., should be more careful when moving to prevent
damage to X-ray tube and other precision fragile devices due to collision.
(59)

2.3.5.2 The Equipment Cleaning:

Preventing dust from entering the interior of the equipment is an
important part of daily maintenance. Entering dust into the interior of the
equipment for a long time, but not removed, will make some components
have poor contact, such as poor contact between the relay contacts, etc.,
and also make some components have short circuits, such as
autotransformer interturn short circuit. Adhere to the daily work and first
clean the equipment and indoor treatment. Dust removal is best to use a
dust collector and try not to use a wet cloth to wipe. (60)
Attention to the Exposure Interval: X-ray machines in the continuous
work should be necessary intervals to make cooling and the surface
temperature of the tube sleeve more than 50–60°C. (61)
The best maintenance of the correct use of medical imaging equipment,
good routine, and regular maintenance of medical imaging equipment can
avoid most of the failures, greatly extending the life of the equipment. (61)
There should be effective maintenance and management of medical
imaging equipment. Engineers engaged in overhaul work should have the
appropriate professional knowledge and certain work experience. (61)
2.3.6 Printing the image

Since the introduction of digital radiography, radiologists have tended to

view digital radiographs, CT, and MRIs on digital monitors at work
stations. To reduce costs, increasing numbers of radiologic institutions
and departments are changing from film copies to lower-priced paper
prints for documenting radiologic findings. (62)