Running head: BALANCING ACT OF DIGITAL RADIOGRAPHY AND PATIENT DOSE

The Balancing Act of Digital Radiography and Patient Dose

Courtney E. Nance
Dixie State University

Running head: BALANCING ACT OF DIGITAL RADIOGRAPHY AND PATIENT DOSE

The Balancing Act of Digital Radiography and Patient Dose

Since 1895, when Wilhelm Conrad Roentgen first discovered x-rays, the evolution of
radiography has continued to progress (Carlton & Adler, 2013). Headway in digital technology
facilitates faster exam times, lowers department costs, decreases image storage space and repeat
radiographs and allows greater image quality and speed. However, the ease of exposing patients
to excessive ionizing radiation has increased with development of new radiology equipment.
Ionizing radiation is radiation capable of producing ions when interacting with matter. It causes
damage by knocking electrons off atoms or initiating chemical changes of human cells (Phillips,
2010). That is why it is imperative for healthcare professionals to be continuously educated about
radiation safety. Many factors play into achieving optimal images while exposing patients to
lowest dose possible and those have only increased with Digital Radiography.
Exposure Index
Digital Radiography systems display an exposure index with each image taken, a
computed set number range of the acceptable exposure to achieve the ideal quality. It does not
indicate patient dose, rather an estimate of the radiation exposure to the detector. Technologists
can determine under or overexposure to the image receptor using the EI, exposure index. It is
inversely proportional to measuring patient radiation exposure due to observing and adjusting the
technique settings caused by an out-of-range EI number reducing patient exposure to radiation.
The natural radiation people annually receive is 3 mGy. An average adult chest radiograph
delivers a skin dose of .15 mGy, making it important to consider patient dose (Scott, 2014).
Multiple x-ray manufacturers. Many vendors of x-ray units result in different systems
of measuring the acceptable exposure range. According to Seeram, the different common ranges

Running head: BALANCING ACT OF DIGITAL RADIOGRAPHY AND PATIENT DOSE

are Kodak (EI 1850-2150) and AGFA (LgM 2.05-2.35) with the lower numbers indicating
underexposure and the high numbers overexposure (Seeram, 2011). Yet some systems like Fuji
(S# 150-300), 150 indicates the high exposure end of acceptable and 300 the low end. This
becomes complicated with the need to share data through institutions and dose registry
databases.
Determining a diagnostic image. Another factor to consider is self QA, quality
assurance, when comparing the exposure index. Before completing an exam, the technologist
determines if the image is diagnostic before sending by using a workstation display lower in
resolution than the radiologists screen display. At times the exposure index will be in the set
range but not appear acceptable to the technologist causing a repeat radiograph. Some problems
are due to exposure field selection error, where the computer figures an exposure index on an
area not of interest on the image. The VA Maryland Health Care System and Rochester General
Hospital in Rochester, NY performed a study comparing technologist repeat ratio to better
quality. The research indicated technologists with higher repeat ratios produced better quality
images than the technologists with lower repeat ratios, producing lower quality images. The ratio
of poor image quality to high image quality was 36% to 64% for technologists with fewer
retakes, versus a ratio of 14% to 86% for technologists with more retakes. In 88% of the cases
tested, the images rejected by the technologists were accepted by the radiologists (Kincade,
2006). This study shows the need for standardizing digital radiography.
Other EI complications. The exposure index has many changing factors and cannot
measure patient dose. For example, not collimating (decreasing the x-ray field of view) enough
or too much. In an automatic exposure control system, three ionizing air chambers are used to
end the exposure when enough density is reached according to the computer. Insufficient

Running head: BALANCING ACT OF DIGITAL RADIOGRAPHY AND PATIENT DOSE

collimation causes excessive scatter radiation to reach the air chambers, terminating the exposure
too soon and creating a low density image. Other factors, like selecting the wrong ionizing air
chamber, lead to incorrect density of the desired body part. Also, forgetting to increase technique
with increased SID and OID will lower density. All play a role in obtaining an in range exposure
index and demonstrate the complications that can arise.
Measuring patient dose. In 2008 the International Electrotechnical Commission and in
2009 the American Association of Physicists in Medicine developed the exposure index as a
standard for measuring the radiation dose to the receptor (Cohen, Cooper, Peirsall & Apgar,
2011). A target exposure index value is set for each exam and varies for body parts making the
exposure index unusable to track patient dose. Therefore the deviation index, DI = 10
log10(EI/EIT), was recently implemented to measure the difference between the target exposure
index (EIT) and actual exposure index (EI) to find the optimum technique for the specific
anatomy of interest and view (Cohen, et al., 2011). A DI value of +1 indicates 25% more
overexposure, showing the technologist needs to decrease exposure which creates a better
monitor for patient dose.
Dose Creep
Quantum mottle is a grainy appearance to the image when not enough mAs is used for a
technique. The growing assumption of increasing mAs to prevent mottle and underexposure has
caused dose creep effect, where increased patient dose can be overlooked because increased
technique no longer leads to overexposed images in digital imaging. ALARA is always a practice
to achieve as low as reasonably achievable patient exposure. The histogram and look up table,
LUT, in digital technology interfere with ALARA by readjusting the pixel values to match the set

Running head: BALANCING ACT OF DIGITAL RADIOGRAPHY AND PATIENT DOSE

exam histogram. This makes density changes minor when using a low technique versus a high
technique allowing dose creep effect. A study by Wang Kei Ma, Peter Hogg and Sue Norton
found that as kilovoltage increases between 40 kV and 55 kV the image quality increases then
stays stable from 55 kV to 120 kV; where image quality increases from .4 mAs on and decreases
after 4 mAs because of saturation of overexposure, supporting the dose creep effect (Kei Ma,
Hogg & Norton, 2014). Digital has introduced wide exposure latitudes with no visual cues of
over exposure to the patient.
Correct technique judgments. Another problem influencing dose creep is finding the
correct technique for a certain body habitus. Distinguishing a portable abdomen x-ray technique
for a large man compared to an overly obese man includes many factors; big boned, organ
alignment, short or large torso. A department technique chart is available for technologists but
does not specify body weight. The easy solution for some technologists is to overexpose,
increasing patient radiation, because the computer will fix the image through the look up table.
It is easy and becoming routine for technologists to use the pre-set techniques on the console and
not consider saving the patient dose. Using the wrong setting can also influence an increased
technique on repeat exposures, such as using a small focal spot size on a lumbar spine
radiograph, using a chest histogram setting for an abdomen x-ray or not realizing the different
facility screen speed systems.
Change with limited education. Digital imaging is still evolving in how to achieve the
optimum image with the lowest patient dose. Technologists educated with film radiography were
introduced digital systems on the job rather in school. Many have created habits, memory tricks
with film procedures and adapted to digital technology, which has created another challenge.
Lower patient dose techniques can be used with digital and it is the technologists job to ensure

Running head: BALANCING ACT OF DIGITAL RADIOGRAPHY AND PATIENT DOSE

that. The lack of consistent information due to continued research found on digital technology
creates an ongoing process of change.
Conclusion
The main objective in converting to the digital system is to decrease patient exposure,
increase image quality/speed of delivery and simplify storage handling. Digital technology has
accomplished these items but has come with side effects, dose creep being the main issue.
Following the ALARA principle includes considering the patients safety and risk of radiation
effects, optimizing radiation use, sharing strategies, and continuously reviewing protocols to
ensure low dose (Scott, 2014.) Digital imagings wide exposure range has led to better quality
images but research needs to be standardized to ensure the best patient care.

Running head: BALANCING ACT OF DIGITAL RADIOGRAPHY AND PATIENT DOSE

References
Carlton, R. R., & Adler, A. M. (2013). Principles of radiographic imaging: An art and a science.
(5th ed.). Clifton Park, NY: Delmar/Cengage Learning.
Cohen, M. D., Cooper, M. L., Peirsall, K., & Apgar, B. K. (2011). Quality assurance: using the
exposure index and the deviation index to monitor radiation exposure for portable chest
radiographs in neonates.Pediatric Radiology, 41(5), 592-601.
Kei Ma, W., Hogg, P., & Norton, S. (2014). Effects of kilovoltage, milliampere seconds, and
focal spot size on image quality. Radiologic Technology, 85(5), 479-484.
Kincade, K. (2006). Study finds link between RT retake rates and image quality. Retrieved from
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Phillips, A. J. (2010). Radiation safety: A growing concern.ERadImaging, 1-13. Retrieved from
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Scott, A. M. (2014). Current issues in radiation dose monitoring and reporting. Radiologic
Technology,85(5), 501-516.
Seeram, E. (2011). Digital radiography: An introduction. Clifton Park, NY: Delmar/Cengage
Learning.