Audit of Adult Chest Radiographs
(PA Views) Done in JPD HTAA,
Kuantan
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 abovementioned 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 substandard (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
Over / under exposed films
Scapulae inside the lung fields
Conning not at the shoulders
24%
15%
12%
10%
Table no. 2 shows the distribution of X-rays according to the scoring.
Table 2: Frequency distribution of radiograph according to scores
(June 2000)
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 3: - Frequency distribution according to ten standard criteria.
Criteria
Correct exposure
Good Inspiration
Symmetrical position of thorax
Proper positioning of scapulae
Good visualization of lung pattern
Whole rib cage included
Sharpness of chest anatomy
Clarity of retro-cardiac area
Proper conning
Identification and markers
Frequency
84%
96%
76%
88%
97%
97%
98%
98%
90%
99%
Remedial Action
Following the study suggestions were invited from the radiographers to over come these problems. The
suggestions werea) 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
Rotated radiograph
Under/ over exposed radiograph
Scapulae in the lung fields
Conning not at the shoulders
Percentage
22%
6%
15%
3%
Table 5: - Frequency distribution of radiographs according to score (Sept. 2000)
Score
No. Of radiographs
Percentage
10
9
8
7
6
5
11
55
23
8
0
3
11%
55%
23%
8%
0%
3%
Total
100
100%
Table 6: - Comparison of PA – CXR in June 2000 & Sept. 2000
June 2000
Standard
Sub- Standard
75%
25%
September 2000
89%
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.